connectingcultures.com.au

Name of Tour:

Start Date:

CLIENT 1 (AS PER PASSPORT):

Title (Mr/Mrs/Ms/Miss):

First and Middle Name:

Surname (CAPITALS):

Occupation:

Nationality (as per passport):

Birth Date:

Passport No:

Client Requirements

Medical/Special Requirements:

# Please attach relevant medical certificate and read declaration (at bottom of this form)

Dietary Requirements:

Rooming Requests (please tick):

Booking No Room Type (please tick):

Emergency Contact Details:

Name:

Phone:

Relationship to Client:

Address Details: Client 1 (all correspondence will be mailed to client 1, unless otherwise requested)

Postal Address:

Postcode:

Home Phone:

Mobile:

Email:

Would you like to receive a copy of our Connecting Cultures newsletter and be contacted about upcoming specials? (please tick)

Travel Insurance is compulsory when traveling with Connecting Cultures and must be purchased no later than when final balance is paid. Would you like to be referred to a travel insurance agent? (please tick)

DECLARATION: I have read, understood and agree to abide by the terms, conditions and responsibilities as outlined. All persons named on this form are fit and physically able to partake in tours unaided and travel throughout the destinations described.

Name:

Date:

Click here to view our Booking Form Terms & Conditions

Passport Expiry Date (dd/mm/yy):