Prices: Your ultimate total price (see below), includes hotel. cruise and all special activities as described, and will depend on the level of your American Queen cabin.

1. Passenger info: please print clearly.

Name (as on your photo ID)__________________________________________________________________

Address________________________________________________________________________

City, State, Zip__________________________________________________________________

Phone___________________________________Email__________________________________________________

2. Passenger info: please print clearly.

Name (as on your photo ID)__________________________________________________________________

Address________________________________________________________________________

City, State, Zip__________________________________________________________________

Phone___________________________________Email__________________________________________________
 

DEPOSITS AND PAYMENT:

• Deposits of $500 USD per person are required to secure space ($1,000 for 2 people).
• Final Payments will be due prior to July 1, 2005

Amount of Deposit paid $__________________

Any special requests?_____________________________________________________________________________

Any special occasions being celebrated?______________________________________________________________

Any special dietary needs?_________________________________________________________________________

Any special medical needs?________________________________________________________________________

CANCELLATIONS:

• Cancellations received in writing more than 90 days before departure are subject to cruise, hotel, and administrative charges of $200 per person.
• Cancellations received in writing 89-46 days prior forfeit 50% of total cost.
• Cancellations received in writing 45 days or less prior forfeit 100% of total cost.

METHOD OF PAYMENT:

A. Check $500 USD per person made payable to: Jim Cullum. 
Mail  deposit to:

NEW ORLEANS ADVENTURE
c/o Don Mopsick
8416 Star Creek Dr.
San Antonio, TX 78251-2331

B. Credit Card: Please print this file, then fill out the information, then fax to 210-684-9166.

Card type (Visa, Master Card, Discover, AMEX only): _______________________

Card Number: __________________________________________________________________

Expiration date: ________________  Card Verification Number (optional)__________________

Name as on the card: ____________________________________________________________

Billing address for card: 

_______________________________________________________________________________

_______________________________________________________________________________

Signature: 

X______________________________________________________________________________
(Required field)

INSURANCE:

We strongly recommend (but it is NOT required) that you insure yourself for any unforeseen circumstances that may cause you to cancel or interrupt your trip.  TRAVEL INSURED INTERNATIONAL offers an inexpensive policy for USA residents.  They also offer coverage for baggage, medical and flight accident.  Please contact us for more information. Click here for the application form (requires Adobe Acrobat Reader).  Insurance must be purchased within 10 days of your initial deposit. 

Please sign (required whether accepting insurance or not) to acknowledge that we have offered you trip insurance, then fax back to us for file.

X ________________________________________________________________________________________
(Required field)

QUESTIONS? Email us at Beth@bethcoxassoc.com or call us at 800-951-4225, When prompted, enter access code "00."

© 2004 Jim Cullum, Jr.