Independent Travel Reservation Form Please affix MIR Corporation 85 South Washington Street, Seattle, WA 98104 recent photograph Tel: 800-424-7289 • 206-624-7289 • Fax: 206-624-7360 Email: email@example.com • www.mircorp.com Please read and complete this form (two pages) carefully, sign the release and send together with your per person deposit to MIR. Include a photocopy of the issuing/photo page of your passport. Participant Information - Traveler 1 Full Name (as listed on passport) Gender Mailing Address City/State/Zip Tel:(Home) (Work) Fax Email Passport No. Exp Date* Date of Issue* Place of Issue* Date of Birth Place of Birth* Citizenship Occupation* Place of Work* (Co. name) Position* Father’s Name (required for trips to Iran only)* * Required for obtaining visa support for your tour. Your passport must be valid for at least six months beyond the tour end date. Participant Information - Traveler 2 Full Name (as listed on passport) Gender Mailing Address City/State/Zip Tel:(Home) (Work) Fax Email Passport No. Exp Date* Date of Issue* Place of Issue* Date of Birth Place of Birth* Citizenship Occupation* Place of Work* (Co. name) Position* Father’s Name (required for trips to Iran only)* * Required for obtaining visa support for your tour. Your passport must be valid for at least six months beyond the tour end date. Please list any previous MIR trips taken In case of emergency please notify (Name / phone number) Dietary restrictions/allergies Please give us an accurate assessment of each travelers’ health and physical condition, including any medical condition and medications which might affect your ability to participate in this trip. International Airfare ❏ I will contact MIR regarding airline reservations ❏ Please send me a suggested itinerary and estimate departing from ❏ I will handle my own air reservations. (Please mail MIR a copy of your itinerary showing arrival and departure flights and times by 30 days prior to departure). Trip Cancellation/Interruption, Medical and Evacuation Insurance MIR Corporation strongly recommends that you purchase insurance. Contact MIR at 1-800-424-7289 or 206-624-7289 or firstname.lastname@example.org for a complete description of policy terms, conditions, exclusions and rates. We can arrange for your purchase of these coverages through us in which case the pre-existing medical condition exclusions will be waived if the premium is paid when you make your tour deposit. Reservations, Deposits and Cancellations I/we enclose a non-refundable deposit in the amount of $300 per person plus insurance premium: $300 per person deposit + $ (insurance) per person = $ X # of travelers = total enclosed $ in the form of: ❏ check ❏ Visa ❏ MC ❏ Amex (If reservations are requested at less than 21 days prior to departure, an expedited booking fee of $100/party also applies) Name on credit card Card number Expiration date Card billing address (if different than above) I authorize MIR Corporation to charge the total enclosed amount - signature: Deposits: Deposits are accepted by check, Visa, MasterCard or Amercian Express. Final land payments may be made by check or credit card for reservations made directly with MIR. If booking through a travel agent, please contact your agent to find out what form of payment they accept. (MIR can accept final payment from travel agents by agency check only). Cancellations: If you cancel your trip please notify MIR in writing. Upon MIR’s receipt of notice the following charges apply (except air tickets and visa fees): cost of cancellation, if received 46 days or more before departure, $300 per person; 31-45 days before departure, 25% of the land tour cost per person; 21-30 days before departure, 50% of land tour cost per person; 15-20 days before departure, 75% of the land tour cost per person; at or less than 14 days before departure, no refund. Visa fees are fully non-refundable once procesing has been initiated. Air tickets are subject to the cancellation policies of the air carriers. On receipt of this completed form, signed release and deposit, we will reserve your space (based on availability). Signature on release required. RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT Please read carefully: This is a legally enforceable waiver of rights BOOKING CONDITIONS: I have carefully read and fully understand the cancellation and payment policies on the Inde- pendent Travel Reservation Form as well as the terms and conditions contained in the current (2007-08) MIR Corporation catalog (page 62, “Traveler Information”). Prices quoted are in US currency, are based on current tariffs and exchanges and are subject to change until all services are confirmed and final payment has been received. Booking Fees: As you can imagine, booking travel and arranging for visa support to developing destinations is time consuming and challenging due to communication and infrastructure restraints, and thus, reservations requested less than 21 days prior to departure, if accepted by MIR, are subject to an expedited booking fee of $100/party. This is a one-time fee which is in addition to the cost of your travel services. For all bookings requested 45 days or less prior to departure, full payment will be due at the time reservations are requested. Final document packets including travel vouchers and local contact information are typically sent 7-10 days prior to departure. I understand that MIR Corporation is an agent for the independent service providers and suppliers that will serve and supply me during the tour, including transportation, accommodations, restaurants, and other travel services. MIR Corpora- tion does not control these independent service providers and suppliers; neither will MIR be responsible for any delay, inconvenience, accident, expense, injury, loss, death or damage whatsoever occasioned through the conduct or default of these service providers or suppliers. Each of the providers and the suppliers is subject to the laws of the country in which the tour takes place. I understand the voluntary signing/returning of this release is a condition for MIR Corporation’s accepting me as a traveler. ASSUMPTION OF ALL RISKS: I voluntarily apply to participate on a tour under the arrangements of MIR Corporation with knowledge of the inherent hazards and risks involved, including but not limited to: motor vehicles, aircraft, trains, boats or any other conveyance, roads, trails and accommodations which are not maintained or operated to standards common in the United States; traveling in remote areas; the forces of nature; civil disturbance; terrorism; government restrictions; high altitude conditions; accident or illness in remote locations without access to rapid rescue or medical facilities; the adequacy of medical attention once provided; consumption of alcoholic beverages; among many unforeseeable other risks (“Risks”). I have considered my own condition and limitations, this tour, its remote locations, potential Risks, and physical demands, and I have concluded that I am physically and emotionally fit and able to participate in this tour. I agree to be responsible for my own welfare, and the welfare of my minor dependents traveling with me, and accept any and all Risks. ACCORDINGLY, I RELEASE AND DISCHARGE MIR CORPORATION, ITS OWNERS, OFFICERS, DIRECTORS, AGENTS, CONTRACTORS, AND EMPLOYEES FROM AND AGAINST any and all liability, causes of action, debts, claims, demand of every kind and nature, whatsoever, which may arise from my participating in MIR Corporation tours, including any claim for property loss, injury, death or damage that I might suffer due to the acts of or the omissions by MIR Corporation, including negligent acts of or omissions by MIR Corporation. This RELEASE is intended to be interpreted as broadly as permissible under Washington State law, and that if any portion of this declaration is held invalid, it is agreed that all other parts shall continue in full legal force and effect. This Release shall be legally binding upon myself, all minors under the age of 18 traveling with me, my family, heirs, administrators, executors, legal representatives and assigns. Any claim or controversy arising out of or relating to any Risks I incur, or concerning the agreement, or the making, performance or interpretation thereof, shall be settled by binding single arbitrator arbitration in Seattle, Washington, in accordance with the rules of an American Arbitration Association which are in existence at the time of the dispute. Exclusive venue and jurisdiction over the parties and the subject matter to this Release shall be in the Superior Court of Washington for King County in Seattle for commencing the arbitration pro- ceedings and enforcing the arbitration award. The rights and obligations of the parties shall be construed under Washing- ton State law. I HAVE READ THE ABOVE AGREEMENT AND VOLUNTARILY AGREE TO SIGN THIS DOCUMENT. NO ORAL REPRE- SENTATIONS OR INDUCEMENTS APART FROM THIS AGREEMENT HAVE BEEN MADE, AND I ACKNOWLEDGE THAT THIS AGREEMENT CANNOT BE ALTERED OR WAIVED, EXCEPT IN WRITING, AND THEN SIGNED AND CONSENTED TO BY BOTH PARTIES. __________________________ _____________________ Signature of Traveler Date __________________________ _____________________ Signature of Traveler Date Both parents or guardians must sign for children under 18 years of age.
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