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Consolidator Group Travel,
Inc. |
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Consolidator Group Travel,
Inc. |
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| CLIA Cardholder: _______________________________________________________________________________ |
| Manager's Name: __________________________________________________________________________________________ |
| Agency's CLIA Number: ______________________________________________________________________________________ |
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Agency Address __________________________________________________________________________________________ |
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Agency City/State/Zip: _____________________________________________________________________________________ |
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Agency Phone: ___________________________________________________________________________________________ |
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Agency Fax : _____________________________________________________________________________________________ |
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Email address: ________________________________________________________________________________________ |
| TRAVEL REQUEST INFORMATION |
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Passenger Name(s): ____________________________________________________________________________________________ |
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Departure date and routing : ________________________________________________________________________________ |
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Return date and routing : __________________________________________________________________________________ |
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Additional information: ________________________________________________________________________ |
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________________________________________________________________________________________________________ |
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________________________________________________________________________________________________________ |
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****Once received we will book the request space for you and contact you with your rate information (in 1 business day)**** |
