| 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.
| Student Travels Magazine | Friend/Family | Teacher/Advisor | Let's Go | |
|
Poster | Berkeley Guides | Other |
| Yes | No | Male | Female |
| Airfare Savings | Insurance Coverage | Worldwide Discounts | Identification |
| Other |
| High School | College Freshman | College Sophomore | College Junior |
| College Senior | Graduate |
| Africa | Asia | Australia | Caribbean | Central America |
| Eastern Europe | Middle East | South America | Western Europe | USA |
| 1 week | 2 to 4 weeks | 1 to 3 months | 3+ months |
| study | work | leisure |
| 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