2009 ITU LD World Championships-Perth, AU
October 24-25, 2009
Travel Request Form (Please print clearly)
Full name(s) (as shown on passport):
___________________________________________________________________________
Address: __________________________________________________________________________
City: _________________________Province:_________Postal Code: ___________________
Tel: (Res)____________________________ (Bus/Cell) ______________________________
Email Address: ______________________________________________________________
Accommodation Request:
*Note there is a minimum of 5 nights that must be booked (Oct. 21-25)
Mounts Bay Waters Apartment Hotel - 1 and 2 Bedroom Apartments
1 Bedroom Apartment 2 Bedroom Apartment
___ Single Occ. (1 king & sofa bed) ___ Single Occ. (1 king, 1 twin & sofa bed)
___Double Occ. (1 King & sofa bed) ___ Double Occ. (1 king, 1 twin & sofa bed)
___ Triple Occ. (1 king, 1 twin & sofa bed)
___ Quad Occ. (1 king, 1 twin & sofa bed)
____ Yes please match me up with someone
Age Range______________________ Male Female Doesn’t Matter (Circle one)
I have made arrangements to share my room with________________________________________________________________________
Full names (as shown on the passport) of others traveling with you who also require air reservations: ________________________________________________________________
____I have made my own arrangements for obtaining an Australian Visa
____ I require Heartland Travel to arrange an Australian Visa for me and my travelling companions
(please fax or scan and email a copy of your passport to Heartland Travel)
____ I have made air reservations on my own for this competition
If you want us to book flights for you please complete the following:
Departure date: ______________________ Return date: _____________________________
Departure city from Canada: _____________________ Arrival City: ____________________
Air Canada Aeroplan #: _____________________
Bikes: Please indicate how many people listed on this form will be taking a bike ________
What are the approx. dimensions of the bike box? ______________________________
What is the approximate weight of the bike box? ____________________________
For any hotel, air reservations, and insurance payments you require, please complete the following:
*Credit card #-Visa or MC: __________________________________________ Exp date: ____/____
Signature of authorization: ____________________________________________________
Insurance coverage: Yes____ No____
If yes, select one package: Deluxe Package _____ Non Medical Package _____
*Date you depart your home in Canada ____________________
*Date you return to your home in Canada ___________________
*We can only insure you for the full dates of your entire trip, not just part of it as per RBC Insurance
Date(s) of birth: (For everyone needing insurance coverage-day/month/year)
___________________________________________________________________________
This is very important. If you have your own air reservations and any other pre paid travel arrangements already booked yourself and your travelling companions, we can cover you for those with the insurance packages listed above. Please indicate below the total non-refundable amounts (per person) of your travel arrangements so we can make sure you are 100% covered for everything you have pre-paid for the competition should you have to cancel. If you do not know these, please contact Heartland Travel for more information and an explanation.
Airfare: _______________________ Train/Bus/Car rental: _______________________
Other: __________________________
Note: Insurance is a very important issue. If you do not want coverage from Heartland International Travel & Tours, we require your signature below. Please remember that if you decline coverage, any/all of your pre-paid travel arrangements (hotel, air, car, train, bus, etc.) are 100% non-refundable should you have to cancel.
Signature: __________________________________________ Date: __________________
In addition to declining insurance on this form, we will send you an RBC Insurance Liability and Release form for everyone declining coverage to fill out and send back to us stating you/they have declined coverage from Heartland Travel.
Additional requests or special notes:
__________________________________________________________________________________________________________________
Contact:
Don or Shannon
Heartland International Travel & Tours
202-3111 Portage Ave.
Winnipeg, MB R3K 0W4
Toll free: 1-866-890-3377 Phone: 204-989-9630
Fax: 204-989-9636
Email: donf@heartlandtravel.ca
or shannonc@heartlandtravel.ca