RetailerForm

Please complete the following and return this portion to us promptly: Company (Travel Supplier)

By checking this box, you have read and understand the details of the Travel Retailer.

Name:

Primary Contact Name:

Address:

Email Address:

Phone Number(s):

Taxpayer ID/FEIN:

Date training was completed:

By signing this document you are confirming that you have completed the presentation and understand the material and certifying that you comply with 18 U.S.C. 1033 reference:

http://uscode.house.gov/view.xhtml?req=(title:18%20section:1033%20edition:prelim)%20OR%20(granuleid:USC-prelim-title18-section1033)&f=treesort&edition=prelim&num=0&jumpTo=true

Signed:

Dated (dd/mm/yyyy):

Signature