*Agency Name:

*First Name:

*Last Name: 

Referred by: NACTA Host Agency Member

Home Address 1:

Home Address 2:

*City: 

*State: 

*Zip Code: 

*Phone Number: 

*Fax Number: 

This will NOT be used for  broadcasting. It will be used to fax a confirmation of your confirmed registration.

*E-mail Address: 

*Important Requirement for Port Seminars
Drivers License # and State or
Valid Passport # and Nationality
Birthdate (mo, day, yr)

DL
PASSPORT
Nationality
Birthdate

*Do you make bookings using a Host Agency?: 

Yes  No

*Are you a member of a Consortium? 

Yes  No   

If you answered Yes which one? 

*%of Leisure Travel you sell:

%

*How many years have you been a travel agent?: 

# of years

*How many years have you been a home-based?: 

# of years

YOUR personal annual sales
(select one)

% of your sales revenue in each of the following categories (must total 100%)

$0 - $250,000
$250,000 - $500,000
$500,000 - $750,000
$750,000 - $1 Million
$1 Million - $1.5 Million
$1.5 Million - $2 Million
$2 Million - $3 Million
$3 Million Plus