JEWISH SINGLES VACATIONS

Summer in America's National Parks Trip  
On-line Application

Please fill in the on-line registration form and submit it to us. This will hold your place for 7 days.

To confirm your reservation, please print this form, sign it and send it to us.  If paying by check, please include it with this form.

If you have any further questions, please e-mail us directly.

Thanks.


FIRST NAME
LAST NAME
ADDRESS
APT. #
CITY
STATE /PROVINCE
ZIP /POSTAL CODE
COUNTRY

HOME PHONE NO.
WORK PHONE NO.
CELL/MOBILE PHONE  NO.
FAX NO.
HOME E-MAIL
WORK E-MAIL

SEX (M OR F)
AGE

SMOKER? YES NO

EMERGENCY CONTACT

NAME
RELATIONSHIP
 PHONE NO.

HOTEL(Check One)

Request a Roommate
Single room (supplemental charge: $399)
I will be sharing with:

SPA PACKAGE (Check One)

Three nights (July 3 to 6) - Double room
Three nights (July 3 to 6) - Single room
Two nights (July 4 to 6) - Double room
Two nights (July 4 to 6) - Single room
No, thank you

Where did you hear about the trip?

CANCELLATION CHARGES

Cancellation charges are $250 from May 6 to June 21, 2003.  From June 22,  the total cost of the trip is non-refundable.  Cancellation charges are regardless of circumstances.  Therefore, we strongly recommend that you purchase travel insurance.

PAYMENT

This application must be accompanied by full payment.  If paying by check, please make check payable to Jewish Singles Vacations.

I am paying  by CHECK   AMEX  
AMOUNT:
CREDIT CARD NUMBER: EXPIRATION:

If paying by credit card, it will be charged today.

When sending this form, please sign and date:
SIGNATURE: DATE

Make checks payable to Jewish Singles Vacations.

Jewish Singles Vacations
P.O. Box 211
Brookline, MA 02446-0002
Telephone:(617) 782-3396