2002

International Student Identity Card Application

Directions:
1. Print out the form
2. Please print in Capital Block Letters using black ink
3. When form is completed Mail to : Premier Travel, 1011 Harlow Road, Springfield, OR 97477 along with a check or money order in the amount of $27.00 ($22.00 for card, $5.00 s&h) Note: add $15 for 2nd day express, $25 for next day express, proof of student status, and one photo (Passport size),
4. Your card will be processed and sent back to you regular mail unless otherwise noted.

Citizenship: __ __ __ __ __ __ __ __ __ __

First Name: __ __ __ __ __ __ __ __ __ __

Last Name: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Number and Street Address (U.S. Addresses Only):

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City: __ __ __ __ __ __ __ __ __ __ __ __ __ __ State: __ __ Zip: __ __ __ __ __

Date of Birth: __ / __ / __ Telephone Number: ( __ __ __ ) __ __ __ - __ __ __ __

E-Mail: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

School Name: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Permanent Address (if different from above)

Number and Street: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City: __ __ __ __ __ __ __ __ __ __ __ __ __ __ State: __ __ Zip: __ __ __ __ __

Telephone Number: ( __ __ __ ) __ __ __ - __ __ __ __

 

I hereby certify that this information is true and understand that any false statements on my part may result in the forfeiture of any benefits associated with the card.

Signature ______________________________________________

Premier Travel ~ 1011 Harlow Road ~ Springfield, OR 97477

2001 International Student Identity Card Application (Page 2)

Please take a moment to fill out the following questionnaire. It is our goal to increase the value and benefits to all our cardholders. In order to reach this goal we need your help. Thank you for your purchase and for your time in filling out this questionnaire.

1. How did you hear about the card? (only one answer). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Student Travels Magazine Friend/Family Teacher/Advisor Let's Go
World Wide Web
Poster Berkeley Guides Other

2. Have you purchased the card before? . . . . . . . . 3. Gender: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No Male Female

4. What is your MAIN reason for purchasing the card? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Airfare Savings Insurance Coverage Worldwide Discounts Identification
Other      

5. Current Grade Level? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
High School College Freshman College Sophomore College Junior
College Senior Graduate    

6. Where are you traveling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Africa Asia Australia Caribbean Central America
Eastern Europe Middle East South America Western Europe USA

7. How long will you be traveling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 week 2 to 4 weeks 1 to 3 months 3+ months

8. What is the main purpose of your trip? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
study work leisure  

9. What is your ethnic origin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Caucasian African American Asian Hispanic
Native American Other    

PLEASE NOTE:

Proof of student status: Provide one of the following:
1. Photocopy of school ID (must be validated for 2001-2002 academic year)
2. Letter on school stationery from registrar or dean (with school seal) stating you are enrolled during the 2001-2002 academic year at an accredited institution and working toward a diploma or degree.
3. Photocopy of transcript/report card for fall 2001, spring 2002, or summer 2002.
Note: An acceptance letter is not sufficient proof.

Some age restrictions may apply on certain student and youth discounts

Premier Travel ~ 1011 Harlow Road ~ Springfield, OR 97477