429-430 Royal Exchange, Old Bank Street Manchester M2 7EP Tel: 0161 839 111; Fax: 0161 839 0000 E-mail: all@itstravel.co.uk ABTA V1178 BOOKING FORM & PASSENGER DETAILS Rome, Italy – with Jane Chipperton DATE OF DEPARTURE: 1 MARCH 2016 TITLE FIRST NAME SURNAME DATE OF RETURN: 6 MARCH 2016 PASSPORT NUMBER DATE OF BIRTH INSURANCE NATIONALITY IF NO – NAME INSURER & EXPIRY DATE Address: Tel: Day: Eve: Mob: Emergency Contact Name & Address: Tel: ACCOMMODATION SPECIAL REQUESTS NOT GUARANTEED Room Type Twin* Single No of Rooms *Name of person with whom you are sharing Please detail below what you wish to pay for: Deposit: £400.00 per person Or full amount if travelling within 8 weeks Travel insurance premiums: UK RESIDENTS ONLY 19-65 £28.07 ; 66-69 £41.60 ; 70-74 £51.74 £ £ £ DEPOSITS INS PREMIUM TOTAL ENCLOSED After 14 days of issue, we cannot refund the premium of your travel insurance policy. How do you wish to pay? INSTALMENT PAYMENTS ARE ACCEPTABLE. I wish to pay by CHEQUE / POSTAL ORDER / CASH / CREDIT CARD (Cheques should be made payable to “ITS”.) If paying by credit or debit card then please complete the details below: (Note that there will be a charge of 2.5% on credit cards only.) Card Type: Mastercard / Visa / Amex / Switch / Solo / Delta (please delete) Sec No Card Number Valid from: / Valid to: / Name on card: I agree on behalf of person names shown on this booking form to accept the Booking Conditions (where applicable) and warrant that I have the authority of all persons named to make the booking subject to these conditions. This tour is subject to English Law. The Booking Conditions and details of travel insurance are as per current ITS brochures and are freely available on request. I acknowledge that they contain certain exclusion clauses and I accept them on my own behalf and on behalf of all other passengers named above. (Note: Bookings will only be accepted by persons over 18 years of age.) Finally ... Please sign here: Actionstrike Ltd Date: Reg. No. 2613382 England VAT Reg. No. 560 4413 67