FIRST CLASS TRAVEL CONCIERGE MEMBERSHIP January 01, 2018 - January 07, 2018 MEMBERSHIP REGISTRATION FORM SUBMIT ONLY ONE REGISTRATION FORM PER MEMBERSHIP Select Your Room Category: --Select One-- Individual/Family ($1,999.00) Corporate/Extended Family($5,999.00) LEAD MEMBER MEMBERS MUST USE THEIR LEGAL NAMES AS THEY APPEAR ON THEIR PROOF OF CITIZENSHIP TO REGISTER TRAVELER one Gender ---Please Select--- male female other U.S. citizen ---Please Select--- yes no Date of Birth TRAVELER two Gender ---Please Select--- male female other U.S. citizen ---Please Select--- yes no Date of Birth ADD ADDITIONAL TRAVELER ---Please Select--- Yes No ---Please Select--- Yes No BILLING INFORMATION Card Type VISA MC AMEX DISCOVER Expiration Date Month January February March April May June July August September October November December (+)add another card PAYMENT INFORMATION Card Type: -Select- VISA MC AMEX DISCOVER Expiration Date Month -Select Month- January February March April May June July August September October November December Year CVV Number Amount to Pay Now: $ (+)add another card SPECIAL REQUEST OR ADDITIONAL INFORMATION
