Burkhalter Travel
 
Traveler Profile    [ * Required Information ]
Passenger Name: Title:
Firm: Department:
Business Address: Home Address:
City/State/Zip: City/State/Zip:
Business Phone/Ext.: Home Phone:
Name as it appears on Passport: * Cell Phone:
Passport Number: * Passport Expiration Date: *
Date of Birth: DD/MM/YY * Gender: Male    Female
Administrative Assistant Name
& Phone Number:
Fax Number:
Email Address: *    
Airline Preferences    [ if any ]
Domestic: International:
Seating Preferences: Window     Aisle    Special Meal Request on International
Flights (Example: Diabetic, Vegetarian):
Frequent Flyer Membership (list airline and number)
Do you want tickets charged to credit Card? Yes    No
If yes, Credit Card Name:  and Credit Card Number: 
Expiration Date: Month:  and Year: 
Car Preferences
  1st Choice 2nd Choice 3rd Choice
Car Rental Company:
Corporate ID Number:
Club Number (i.e., Avis Wizard No., Hertz No. 1, etc.):
Vehicle Size:
AAA Number:    
Special Request (i.e., 4-door, etc.):    
Hotel Preferences
  1st Choice 2nd Choice 3rd Choice
Hotel Chain:
Corporate ID Number:
Club Number (i.e., Marriott Marquis):
Special Request (i.e., ground floor, smoking or non, etc.):    
Guarantee Hotel Reservations Always    Late Arrival Only
 Check here if Credit Card information is same as above mentioned.
Credit Card Name:  and Credit Card Number: 
Expiration Date: Month:  and Year: 
NOTE: TRAVELER PROFILE REQUIRED FOR 24-HOUR TRAVEL SERVICES.