Last Name/First Name: _____________________________________________

Company Name: _____________________________________________________

Address: __________________________________________________________

Phone: __________________________ Fax: ____________________________

Email address: ____________________________________________________

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13 digit lost ticket number: ______________________________________

Amount paid for lost ticket: ___________ Date of purchase: ________

City where lost ticket was purchased: _____________________________

List all lost flight segments:

from ____________ to ____________ to ____________ to ____________

Were any of the above segments used before the ticket was lost?

If yes, which ones? _______________________________________________

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Was a replacement ticket issued? _______

by airline? ________ by travel agency? ___________

Date replacement ticket was issued: ______________

Ticket number: ___________________________________

Amount paid for replacement ticket: ______________

Lost ticket fee collected? _______________________

Form of payment for replacement ticket: __________

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Fax completed form to Conlin Travel at 734 677-3134