Piedmont Travel

144 N. Cherry St., Suite 2,
Kernersville, NC 27284


Online Traveler Profile Form


Personal Information

Full Legal Name

Male   Female 

Business Address:


Home Address:


Passport Information:


Airline Preference & Frequent Flyer Information:

Aisle   Window   

Preferred Airlines

Account Number


Note: The name on your ticket must match the name listed on your frequent flyer account to receive credit.

Hotel Preferences & Frequent Guest Information

Non-Smoking  Smoking  King Bed  2 Double Beds 

Preferred Hotel Chains

Frequent Guest Number


Rental Car Preferences & Express Rental Information

Economy Car  Intermediate Car 
Compact Car  Full Size Car 

Preferred Rental Car Vendors

Express Rental Personal ID Numbers


Additional Information

Credit Card Information

Card Type*

Name On THe Card*

Account Number*

Expiration Date*

CCV Number*

A Credit Card is Mandatory to Book Hotel Rooms
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Note:Your information is delivered to Piedmont Travel via an encrypted format for your protection and security.However, you may want to call us on the telephone with some fields such as credit card account numbers and passport information.Please understand Piedmont Travel group is not for information being sent via the internet.
Note:Upon successful submission a "Thank You" page will display.

Piedmont Travel

144 N. Cherry St., Suite 2,
Kernersville, NC 27284

(336) 992-2828
(800) 650-7003 Toll Free