Travel Agent Trip & Information Request

Please complete the form below to reach one of our travel consultants and receive personal service or call us at 800.377.9463. We respect your privacy. All information will be used solely by Southwind Adventures and will not be rented or sold to any individual or company.

Your Information: Fields marked with a star (*) are required.

First Name:*
Last Name:*
Agency Name:*
Agency Address:*
City:*
State/Province:*	Choose a State/Province Outside US or Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
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Postal Code: if outside the US
Country: if not US
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Fax:
IATA or ARC #:
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Additional Information:

How did you hear about Southwind Adventures? Please be specific (e.g. name of referral, publication, internet search engine, website, etc.).
How many people are in your client's party?	1 2 3 4 5 6-9 10+
When are your clients planning on traveling to South America?	within 3 months 3-6 months 6-12 months 12-18 months 18+ months
What is the destination of your client's party? Hold down the Ctrl key to select more than one	Amazon Argentina Brazil Bolivia Chile Ecuador/Galápagos Patagonia Peru Venezuela
Preferred level of accommodations	First-Class 4-star Luxury, 5-star
Price range per person (excluding air)	$3000-3999 $4000-4999 $5000-5999 $6000-6999 $7000-7999 $8000-8999 $9000-9999 $10,000-11,999 $12,000-13,999 $14,000 or higher
Yes, I would like to subscribe to Southwind Adventure's periodic e-newsletter.
I am interested in learning more about:

	Custom or Private Trips  Hosting a client night  Press releases or images for my agency's newsletter  Other, please specify below:
Additional comments/questions/details: