Registration Form

Thank you for trusting Kierra Murphy with your booking! Please NOTE this form does NOT confirm your travel, we will take this information and send you a separate confirmation once booked.

Travel Advisor's Name *

Travel Advisor's Email Address *

Kindly ensure that the names you are providing for yourself are the legal names as per your passports. Please note that misspelled or incorrect names could cause denial of boarding!

Title *

First name *

Last Name *

Middle Name or Initial (if/as shown on passport)

Please ensure your middle name entered above exactly matches your passport. You may be denied boarding if it is not the same as your passport!

Example: if your passport says "Donna M. Smith", you would only enter the value of 'M' in the Middle name box above.

Example #2: If your passport says "Donna Margaret Smith", you would enter the value "Margaret" above. The value must be the exact same as your passport.

Date of Birth (DD/MMM/YYYY) e.g. 01/JAN/2023 *

Issuing country of Passport

Issuing city of Passport

Issuing Authority of Passport

Passport Number

Passport Expiry Date (DD/MMM/YYYY) e.g. 01/JAN/2023

Passport Date of Issue (DD/MMM/YYYY) e.g. 01/JAN/2023

Optional (Upload an image of the Picture Page of your Passport)

How many Passengers for this registration form? *

Billing Address

Your Email Address *

Please confirm email address *

Email address is required in order to receive a copy of the terms and conditions

Email address is required in order to receive a copy of the credit card authorization

Phone Type *

Phone Number *

Mailing Address * 🛈

Address Line 2

City *

State/Province *

Zip/Postal Code *

Passenger 2

Title *

Passenger 2: First name

Passenger 2: Middle Name or Initial (if/as shown on passport)

Passenger 2: Last Name

Date of Birth (DD/MMM/YYYY) e.g. 01/JAN/2023

Issuing Country of Passport

Issuing City of Passport

Passport Number

Passport Expiry Date (DD/MMM/YYYY) e.g. 01/JAN/2023

Passport Date of Issue (DD/MMM/YYYY) e.g. 01/JAN/2023

Relationship to Passenger 1

Optional (Upload an image of the Picture Page of your Passport)

Passenger 3 (if applicable)

Title *

Passenger 3: First name

Passenger 3: Middle Name or Initial (if/as shown on passport)

Passenger 3: Last Name

Date of Birth (DD/MMM/YYYY) e.g. 01/JAN/2023

Issuing Country of Passport

Issuing City of Passport

Passport Number

Passport Expiry Date (DD/MMM/YYYY) e.g. 01/JAN/2023

Passport Date of Issue (DD/MMM/YYYY) e.g. 01/JAN/2023

Relationship to Passenger 1

Optional (Upload an image of the Picture Page of your Passport)

Passenger 4 (if applicable)

Title *

Passenger 4: First name

Passenger 4: Middle Name or Initial (if/as shown on passport)

Passenger 4: Last Name

Date of Birth (DD/MMM/YYYY) e.g. 01/JAN/2023

Issuing Country of Passport

Issuing City of Passport

Passport Number

Passport Expiry Date (DD/MMM/YYYY) e.g. 01/JAN/2023

Passport Date of Issue (DD/MMM/YYYY) e.g. 01/JAN/2023

Relationship to Passenger 1

Optional (Upload an image of the Picture Page of your Passport)

Passenger 5 (if applicable)

Title *

Passenger 5: First name

Passenger 5: Middle Name or Initial (if/as shown on passport)

Passenger 5: Last Name

Date of Birth (DD/MMM/YYYY) e.g. 01/JAN/2023

Issuing Country of Passport

Issuing City of Passport

Passport Number

Passport Expiry Date (DD/MMM/YYYY) e.g. 01/JAN/2023

Passport Date of Issue (DD/MMM/YYYY) e.g. 01/JAN/2023

Relationship to Passenger 1

Optional (Upload an image of the Picture Page of your Passport)

Should you have more than 5 passengers travelling, please submit details in the additional information text box below

Please submit your credit card info below

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Your Travel Agent has requested that you approve a credit card charge later on this form. The fields below can be used to securely communicate a credit card to your travel agent. You may skip this step, if you do not wish to communicate a credit card to your travel agent.

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Would you like to share your Credit Card information with the Travel advisor to store on file? *

Name on Card

Amount to be charged

Credit Card Number

Expiration Date (mm/yy)

Any notes for your travel agent regarding your credit card

Emergency Contact Info (Optional)

Would you like to add an Emergency Contact? *

Emergency Contact #1 Name

Emergency Contact #1 Phone

Emergency Contact #1 Email

Emergency Contact #2 Name

Emergency Contact #2 Phone

Emergency Contact #2 Email

Your booking is non refundable and no changes are permitted unless otherwise stated

We strongly recommend the purchase of Travel Insurance. Would you like a quote on Travel Insurance? *

We've already discussed, please ADD ON the insurance quoted to me

Send me a quote for the Cancel For Unforeseen Reason (CFUR) coverage

Send me a quote for the All-Inclusive Package (Most inclusive: Includes Trip Cancellation, Interruption, and Medical, as well as Baggage loss or delay, travel accident, etc.)

Send me a quote for Non Medical Package (Includes Cancellation & Interruption, but NO Medical coverage)

I'm not sure could you call me to discuss further?

I am DECLINING all travel insurance and will not hold the Travel Agent responsible for any potential losses that may occur

Any Additional Comments/Requests for your Travel Advisor