Registration

First Name:
Middle Initial:
Last Name:
Email:
Date of Birth (DD-MM-YYYY):
Home Phone:
Mobile:
Nationality:
Gender:	Male Female
Occupation:
Passport number & expiration:
Country of issue:
Deposit (non refundable) - US$500.00 per person/Final payment: March 20th, 2010
Emergency Contact (someone who is not traveling with you)
Name:
Telephone No:
I would like to have a single room:	Yes No
If NO, please provide your roommate’s name below, if you do not provide a roommate name, you will be billed for a single room until one is provided).
Roommate name:
Do you wish to purchase travel insurance? If Yes the Cost is US $159.00	Yes No
Authorized Signature/Approval: (Type Name as confirmation):
Date (DD-MM-YYYY):
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