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New Agency Application

Agency Information Travel Agency Name: Address: City/State/Zip: Owner's Name: Manager's Name: Phone Number: Fax Number : Email: Agency's Web Site (URL): ARC Accredited Number or CLIA : Are you affiliated with a consortium? If so, please indicate their name(s): Travel Industry Background Are you an independent or outside agent?: Do you provide storefront access to your clients or are you a homebased agency?: Professional References: (company name, and phone number) I hereby consent to receive facsimiles & e-mails of advertisements and promotions from Vacation Express and any of its travel partners : Yes No Owner's Name: Date: To complete your application: In order to comply with Internal Revenue Service requirements for Form W-9 information, we are requesting your federal tax identification number. IRS Code Section 6019, recipients payments are required to provide federal tax indentification numbers to payers. Section 6676 of the Code currently provides for mandatory backup withholding of 31% for failure to give an identification number to a payer (W-9 pdf). Please also include a copy of your ARC accreditation letter or your CLIA certificate. After saving your documents(W-9, ARC/CLIA Accreditation Certificate), print, and fax completed forms with owner's signature to: 404-393-4828 or mail completed forms with owner's signature to: Vacation Expess, Attn:Sales, 301 Perimeter Center North Suite 500 Atlanta, GA. 30346.