To: Off-line Travel Request

American Airlines, Inc.

P.O. Box 619616 MD 5141

DFW Airport, TX 75261-9616

From: _________________________________ ____________________________

Name of Retiree (Please print) Employee Number

_______________________________________________________________________________

Street Address

_________________________________ ____________________________

City, State, and Zip Code Telephone Number

Place an "O" in the far left column in front of any city (cities) where a stopover is planned.

First Class is not available at the 90% discount.

Note: Please fill this form out completely, sign and return it to the address listed above along with a PHOTOCOPY OF YOUR TRAVEL CARD AND A GOVERNMENT ISSUED PHOTO I.D. Upon approval and processing, your ticket(s) will be mailed to the address you provide on this form. All unused ticket(s) may be returned to the above address for credit. Tickets must be paid by credit card. Please provide credit card information below:

Charge To:

Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp __ __ / __ __

Credit Card Holder Signature: _________________________________________

If I travel reserved space, I am permitted to make reservations with the carrier(s) concerned. If I travel space available, I will be required to contact the carrier to order the flight/meal list.

________________________________________________________ _____________________

Retiree Signature Date

_________________________________________________________ _____________________

Travel Eligibility Approval/Signature Date

_________________________________________________________ _____________________

Agent Approval/Signature Date