Global Group Travel – Criminal Self-Disclosure

1

Personal Information

Full Name

Date of Birth

Nationality

Phone Number

Email Address

Passport Number

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

2

Criminal Conviction Affirmation

I hereby affirm that as of this date, I have NOT had any criminal convictions in any city, state or country, resulting from criminal behavior other than minor traffic/driving violations. I give full consent and authorization for Global Group Travel to investigate my background if deemed appropriate, concerning criminal proceedings.

I confirm and agree to the above statement.

3

Criminal Violations (if applicable)

If you have had criminal violations, please list the dates, location, violation, and outcome of each charge.

4

Residences – Past 10 Years (New Tour Representatives)

List all residences for the past 10-year period, starting with your most recent residence.

5

Attestation of Accuracy

I attest that the information submitted is true and correct.

I confirm that all information provided in this form is accurate and complete to the best of my knowledge.

6

Electronic Signature & Date

Electronic Signature

Your signature will appear here

By typing your name above you are applying your electronic signature — legally binding

Printed Full Name

Date