Cruise Questionnaire

1 Lead Traveler Information

2 Desired Travel Information

3 Passenger(s) Information

Today's Date*
Date Format: MM slash DD slash YYYY
How did you hear about Time to Split?*
Full Name*
First Middle Last
Email
Main Phone Number*
Preferred Method of Communication*
- Email
- Phone Call
- Text
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Seniors (55+)*
Number of Adults (Ages 18-54)*
Number of Youths (Under 17 years)*
How Many Guests per Room?
Room #1 Room #2 Room #3 Room #4

No more than 5 guests in a room.
Special Circumstances I need to consider...*
- Mobility Issues need to be considered
- Special Dietary requirements to be considered
- Someone in the group is Active Military, Retired Military, Fire, EMS or Police
- Someone in the group is pregnant
- None of the above

First Name	Middle Name	Last Name	DOB	US Citizen?

First Name	Middle Name	Last Name	DOB	US Citizen?

First Name	Middle Name	Last Name	DOB	US Citizen?

First Name	Middle Name	Last Name	DOB	US Citizen?

Room #1	Room #2	Room #3	Room #4

First Choice	Second Choice	Third Choice

Room #1	Room #2	Room #3	Room #4