US Dollar Booking Form for printing and posting or faxing to EWP

TripDatesCode (if known)
First Applicant
Mr/Mrs/Ms
 		Surname
 		First Names
 
Nationality
 		Date of Birth
  		Occupation
 
Passport Number
 		Expiry Date
 		Date and Place of Issue
 
Phone (home)
 		Phone (work)
 		Phone (when on trip)
 
Fax
 		Email
 		Work address*
 
Address
StreetTown
PostcodeStateCountry
Second Applicant
Mr/Mrs/Ms
 		Surname
 		First Names
 
Nationality
 		Date of Birth
  		Occupation
 
Passport Number
 		Expiry Date
 		Date and Place of Issue
 
Work address*
Other information eg. special diet, other address, single supplement, vegetarian
 
 
 
Credit Card Payment: Deposit (10% of trip cost) or full payment if within 8 weeks of departure
 
 
Please debit my card for ................................ US Dollars
(Card payments will be taken in GB£s - using the Currency Converter spot rate. There is a 2% handling charge for final balance payments by credit cards (0% for debit cards.)

Card Type and Number
 		Issue Number
 		Valid from (mm/yy)
 		Valid till (mm/yy)
 		3 digit security no.
 
Cardholder's name (as on card), address and telephone (not mobile) if different to above:

 

Applicants are required to have their own personal insurance for the trip; this should be organised before payment of final balance.
For advice on available policies please contact us.
Application: I have read and agree to the EWP Booking Conditions.
Applicants under 18 must have this section signed by a parent or guardian.
 
Signature(s) ______________________________    Date _________
Send this completed form with credit card details to:
EWP, Haulfryn, Cilycwm, SA20 0SP, United Kingdom.
To discuss your booking and/or give us your credit card details by phone ring: Tel. +44 (0) 1550 721319
This form may be faxed to us - suitable for credit card payments Fax. +44 (0) 1550 720053
Email: ewp@ewpnet.com - do not send credit card details by email.
*The work address is only needed for those applying for Kyrghiz or Uzbek visas.

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ALW 16/7/06