The Living Torah Tour!�
10-26, 2004
Name
(as on passport) _________________________________________________________
Passport number ________________ Date issued _____________ Country ________
I
do not have a passport but have applied for it (��� ) Yes����
Citizen of _____________________
Date
of birth _____/_____/_____���������������������������� Sex��� ( )M��� ( ) F
Address
____________________________________________________________________
City
____________________ ST ____ Zip_________
Home
phone (���� ) ________________Work (����� )________________
Fax (���� )________________
E-mail
___________________________________���������
Smoker���� (�� ) Yes (��
) No
Roommate�s
name (if known) _________________________________________________________
What
is your occupation (or retired from)
________________________________________________
Do
you prefer single accommodation? ( ��)
No (�� ) Yes��� Cost $549
I
would like my nametag to read
_______________________________________________________
Medical History–be specific in case we may need to be of assistance to you.
Special
medical condition(s)___________________________________________________________
Disability
or limitation ________________________________________________________________
Prescription
medications _____________________________________________________________
Primary
physician�s name/phone number ________________________________________________
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Tour
Cost from
York
Immediate deposit��������������������������� ��� -300
Second payment by July 1 � ����������� �-1200
Balance due by September 1����� $1855
Price
includes all taxes and tipping.
Brochure
price reflects a cash discount. $300 deposit must be by check.� Other payments may be made by Visa, Mastercard, or American Express for a 5% non-refundable
transaction fee.
Make
checks payable and mail to Hatikva Ministries–Trust
Account, 455 Country Club Loop, Paris, TN 38242.� Phone
and numbers.
In
case of emergency, please notify: Name� _____________________________________________
Address
____________________________ City ____________________ State ____ Zip ________
Home
Phone (���� ) _______________ Work (���� ) _______________
By
completing this form, I agree that neither Hatikva
Ministries nor anyone acting as agents on their behalf are responsible or
liable for loss, damage, theft of luggage or personal belongings, personal
injury, accidents, or illness.�
Travel Insurance Applications Available
on Request
IMPORTANT
NOTICE: Please register
to avoid disappointment and get help
making your domestic flights.