Botswana Departing on July 19, 2018

Home , Nxai Pan National Park

RESERVATION FORM: (Please Print) TOUR CODE: 18AFL0719/ UPENN Enclosed is my deposit for $ ______($1,000 per person for the main trip and $250 for each extension) to hold ______place(s) on the Wildlife Safari to Botswana departing on July 19, 2018. Cost is $8,695 per person, double occupancy, land and all air within Southern Africa. Sample international air from Philadelphia is $2,690 including departure taxes and fuel surcharges (subject to change).

Final payment due date is April 18, 2018. All final payments are required to be made by check or money order only. Please charge my deposit to my credit card: oMasterCard oVisa oDiscover oAmerican Express

Name on Card ______Card Number ______EXP_____CVN____

NAME (as it appears on passport): o Mr. o Mrs. o Ms.______

NAME FOR NAME BADGE IF DIFFERENT FROM ABOVE: 1)______

2)______

STREET ADDRESS: ______

CITY:______STATE:______ZIP:______

PHONE NUMBERS: HOME: ( )______OFFICE: ( )______

MOBILE: ( )______FAX: ( )______

EMAIL ADDRESS: ______Penn Alumni Travel E. Sweeten Alumni House 3533 Locust Walk 19104-6226 Philadelphia, PA PHOTO CREDITS: © Classic Escapes; © Ron Magill; © Desert and Delta The two of us above are sharing a room and, where possible, would like a room with: Safari; © Okavango Camp. Classic Escapes protects our planet. o One Bed o Two Beds I am sharing with ______(form sent separately) I need assistance in securing a roommate. I understand if the University of Pennsylvania Alumni Association or the tour operator cannot locate one for me by final payment date, I agree to pay the additional single. I prefer to share with: o Smoker o Nonsmoker I/we wish to participate on the optional extensions: o $3,695 for the Chobe NP & Victoria Falls post-extension o $2,795 for the pre-extension to Cape Town BOTSWANA I/we desire single accommodations, if available, and will pay the single supplement additional cost of: o $2,995 for the main trip o $1,395 for the Chobe National Park & Victoria Falls post extension o $995 for the pre-extension to Cape Town Desert Sunset, Delta Dawn Please make my/our round-trip air reservations on the group flights from Philadelphia via Delta Air Lines. Featuring Penn Professor Michael Weisberg (Other departure cities available upon request; prices quoted at time of request.) Please make domestic round-trip air reservations for me from my home city: ______to connect with the group flights and let me know the additional cost. July 19 to 30, 2018 I/We will make own air arrangements and will provide you with an itinerary before trip departure. Adventure is wrapped in luxury in Botswana, where you wing your way from camp to WE STRONGLY RECOMMEND THAT YOU OBTAIN TRAVEL INSURANCE. RESERVATIONS ARE ACCEPTED camp on small planes. No lines, no check-in, just the cheerful hello of the pilot as he SUBJECT TO TOUR CONDITIONS AND WILL BE CONFIRMED ONLY IF ACCOMPANIED BY COMPLETED FORM SIGNED BY THE TOUR PARTICIPANT(S). tosses your duffle in the back of your ‘taxi in the sky.’ Visit the Kalahari Desert and the I/WE HAVE READ THE CONDITIONS OF TRAVEL ON THIS BROCHURE AND UNDERSTAND AND AGREE TO otherworldly Makgadikgadi Salt Pans, where a glowing, white expanse of natural salt THE TERMS AND CONDITIONS STATED HEREIN: deposits create glittering mirages that seem to reach out into the horizon endlessly. Nearby the Nxai Pans are home to an array of animal and plant life, including the giant

SIGNATURE: ______DATE:______“upside down” Baobab trees that make the African skyline so spectacular. Then, take in the spectacular view over the Okavango; a wetland wilderness of looping channels, islands forested with palms and wide grassy floodplains. SIGNATURE: ______DATE: ______Penn Alumni Travel is proud to offer valuable trips and programs to alumni and friends through a number of partnerships. Any revenue that may be generated from Penn Alumni Travel above our program expenses supports other Penn Alumni programming. Please Make Checks Payable to And Send to: Classic Escapes 58-25 Queens Boulevard Woodside, NY 11377 YOUR ITINERARY Optional Pre-Extension to Cape Town Optional Post-Extension to Your Faculty Host Chobe National Park & Victoria Falls Victoria Falls, DAYS 1/2 ~ USA/JOHANNESBURG on the remote Nxaragha Island. Activities here Zimbabwe Michael Weisberg FAIRLAWNS SANDTON HOTEL (Meals Aloft,D) center around mokoro (dugout canoe) rides, boat CHOBE Professor and Chair of Okavango Get set for your adventure as you board your excursions, and walking safaris. See the delta from Philosophy, University of overnight flight to Johannesburg, where you will water level and relax as you glide through quiet, Pennslyvania & Co-director be met and escorted to your hotel. Welcome to reed-lined channels. Pels Fishing Owl and Wattled Camp Moremi Leroo La Tau of the Penn Laboratory for Jo’burg, as the locals say. The vitality of South Crane are observed regularly in the area. In all, more Maun Africa’s largest city is reflected in the gleaming than 600 species reside within the 7000 square Understanding Science facades of abstract modernist skyscrapers and miles of islands, marshes, flood plains, and channels the mercurial flow of its financial center. Gold was of which the Okavango is comprised. Feel the beat Dr. Weisberg is a discovered in the adjacent Witwatersrand area of Africa beneath your feet on a walking safari, and philosopher of science in 1886. Its nickname, “the Rand” later became take a boat through the reeds to spot elephant, red CENTRAL KALAHARI GAME RESERVE whose work focuses on methodological the name of South Africa’s official currency. lechwe, zebra, wildebeest, giraffe, baboon, monkey, Pre-Tour Extension issues in biology, chemistry, and the social You will be staying at The Fairlawns Boutique warthog, and buffalo, along with major predators to Cape Town sciences, and also the public understanding of Hotel & Spa situated in the heart of Sandton, the such as lion, leopard, and hyena. If you are lucky, KALAHARI exclusive residential and business area north of spot the elusive sitatunga antelope which have been DESERT Maun science. Much of Dr. Weisberg’s recent work Johannesburg. known to sleep in the water, with only their nostrils BOTSWANA has focused on biological education beyond resting above the water’s surface. the classroom from alumni travel to working Your adventure begins with a delightful retreat in Continue your adventure to Chobe National Park in DAY 3 ~ CRADLE OF HUMANKIND Johannesburg with indigenous children in the Galápagos Cape Town, one of the loveliest cities in the world. Botswana, home to some of the largest elephant FAIRLAWNS SANDTON HOTEL (B,L) DAYS 9/10 ~ OKAVANGO DELTA Destination archipelago. He believes that the best way Today’s drive takes you to the Cradle of Humankind CAMP MOREMI (B,L,D Daily) View Table Mountain and take the coastal route herds on the continent. Stay at Chobe Game Entry/Departure Light Aircraft to learn about conservation, ecology, and World Heritage Site, where research has been Fly to the elegant Camp Moremi, shaded from the to the Cape of Good Hope to discover charming Lodge in the heart of the park and be pampered Post-Extension evolution is to get up close and personal carried out at 13 fossil sites, 7 of which have yielded African sun by a forest of ancient ebony trees. You’ll seaside towns, spectacular wildlife, and the comical with superb service and cuisine. Then, head to Inbound Flight Cape Town hominid remains. The Sterkfontein Caves, which be thrilled by the excitement of tracking animals African penguins at Boulders Beach. Tour the brilliant Zimbabwe for the idyllic experience of Victoria Pre-Extension with diverse wildlife and ecosystems be it in have produced the most complete skeleton of in open 4X4 vehicles and boating up channels and Kirstenbosch Botanical Gardens, and spend a day Falls. This incredible spectacle — “The Smoke That Philadelphia, South America, or Africa. a 3.3 million year old Australopithecine, is a tour across lagoons, all the while viewing the goings on of in the famed Boland Valley wine region. Visit the Thunders,” as it is known to locals — is the world’s highlight. the delta residents. Moremi Game Reserve supports settlement of Khayelitsha with a township guide, and largest waterfall. Enjoy a sundowner cruise on the For More Information or Reservations the most diverse habitat and animal populations get an eye-opening historical tour of Robben Island. Zambezi River and visit a rural village to experience DAYS 4/5/6 ~ MUAN/MAKGADIKGADI/NXAI in Botswana, with possible sightings of wild dog, Kathy Pluas at Classic Escapes age-old traditions. PANS/KHUMAGA VILLAGE cheetah, and leopard being highlights. Resident 800.627.1244 LEROO LA TAU (B,L,D Daily) species include lion, elephant, buffalo, hippo, giraffe, Fly to Maun and board a light aircraft to Leroo La hyena, zebra, kudu, lechwe, tsessebe, and Sable and Your Journey Costs Your Extensions Costs [email protected] Tau at the edge of Makgadikgadi Pans National Roan antelope. July 19 to 30, 2018 Cape Town – Departs July 15, 2018 Park, named for ancient Lake Makgadikadi, prices per person prices per person Conditions of Travel which disappeared thousands of years ago. What DAYS 11/12 ~ MAUN/JOHANNESBURG/USA remains is a collection of salt pans that cover (B, Meals Aloft) • $8,695 land and air between camps in Africa, • $2,795 double occupancy. HOW TO BOOK: Fill out the reservation form and whatsoever arising from any cause whatsoever double occupancy. send it, along with the relevant deposit as shown, and without restricting the generality of the approximately 6,200 square miles due south of the Enjoy a last wildlife run this morning and a hearty • $995 single supplement. to: Classic Escapes, 58-25 Queens Blvd. Woodside, aforegoing shall particularly not be responsible for Okavango Delta. The camp is situated on the banks breakfast before flying back to Johannesburg via • $2,995 single supplement. NY 11377. Upon receipt of your signed reservation loss or damage arising from any errors or omissions Victoria Falls – Returns August 3, 2018 form and deposit, we will, subject to availability, contained in its brochure or other literature, loss or of the Boteti River and commands superb views. Maun where you connect with your overnight • $2,690 estimated international airfare from Next day, drive to Nxai Pan National Park. These flight to the U.S.A., bringing home with you the prices per person reserve your spot on the tour. You may consider damage caused by delays, sickness, theft, injury, or Philadelphia, including airline taxes and fuel your booking confirmed when you receive a death. In addition the Company shall have the right pans transform during the rainy season between memories of all the wonderful sights of Southern surcharges. Other departure cities available • $3,695 land only. confirmation notice and invoice from us. at any time at its discretion to cancel any trip or the July and October, when they fill with water and Africa. upon request; prices quoted at time of request. • $1,395 single supplement. remainder thereof or make any alteration in route, their stark whiteness becomes lush greenery. Year RATES: Rates are based on the minimum number accommodation, price or other details and, in the round, small populations of springbok, giraffe, and of guests outlined in this document, plus airfare event of any trip being rendered impossible, illegal gemsbok can be found, but during the wet season, costs and other factors and are subject to change. or inadvisable by weather, strike, war, government Your Journey Includes Though it is rare for Classic Escapes to make a price or interference or any other cause whatsoever, their numbers increase significantly, and herds of adjustment after promotion of an itinerary, we the extra expenses incurred as a result thereof zebra and wildebeest arrive bringing with them • Roundtrip flight between Johannesburg and Maun. • Laundry and all local beverages during safari in do reserve the right to assess a surcharge if the shall be the responsibility of the passenger. The Company may at its discretion and without liability opportunistic predators such as hyena and lion. • All flights between the camps. Botswana except for Champagne and imported minimum is not met, or if increases are forced upon Visit Baines Baobabs, an oasis of venerable baobab us by airlines or other partners. or cost to itself at any time cancel or terminate the • Flights between Cape Town and Johannesburg on spirits. guest’s booking and in particular without limiting trees. These “upside down” giants are now part the generality of the aforegoing it shall be entitled the pre-extension. • Complimentary bottled water in vehicles INSURANCE: It is a condition of booking, that the of a protected national monument, providing sole responsibility lies with the guest to ensure to do so in the event of the illness or the illegal or a shady vantage point from which to view the • Flight between Victoria Falls and Johannesburg on throughout. that they carry the correct comprehensive travel incompatible behavior of the guest, who shall in desolate beauty of the Kudiakam Pan. On your and medical insurance to cover themselves, as such circumstances not be entitled to any refund. the post-extension. • All applicable hotel and lodge taxes and gratuities well as any dependents/traveling companions last day, drive to the nearby Khumaga Village for • Superior accommodations throughout as indicated for baggage handling. for the duration of their trip. Classic Escapes and CANCELLATIONS: Cancellations are only effective an enlightening cultural experience. An open-air the University of Pennsylvania, including their on receipt of written notification. The following dinner with traditional storytelling will bookend Caves Of Cradle Of Humankind or similar. • All park entry fees and sightseeing as specified. representatives, employees and agents will take per person fees are applicable on this tour: your day. • All meals while on safari. Other meals as specified in • Gratuities to drivers and other conveyance no responsibility for any costs, losses incurred or • Up to April 18, 2018, $300 handling fee, suffered by the guest, or guest’s dependents or plus $250 non-refundable deposits given to Did you know ... itinerary. attendants. traveling companions. overseas suppliers. DAYS 7/8 ~ OKAVANGO DELTA Batswana is the plural term for people • All wildlife viewing by private 4X4 open vehicles, • Complimentary baggage tags and passport wallet. • April 19 to May 5, 2018, deposit is forfeited. CAMP OKAVANGO (B,L,D Daily) RESPONSIBILITIES: Neither Classic Escapes (the • May 6 to May 20, 2018, less 75% of tour cost on driven by professional driver/guides. • Complimentary Emergency Evacuation Insurance. Fly to one of the world’s most distinctive regions who live in Botswana. The singular Company), the University of Pennsylvania, nor any both the main trip and the extension. • After May 20, 2018, no refund is possible. and largest inland water systems, the Okavango • Professional guide will accompany the group with a person or agent acting for, through, or on behalf of term is Motswana. the Company shall be liable for any loss or damage These cancellation fees are also in addition to Delta and to the exceptional Camp Okavango minimum of 10 travelers. any imposed by airlines.

“Sub-Saharan Africa is a tremendously beautiful part of the world. There’s a spirituality to it — there must be few people who visit the area and don’t feel moved by it. Once you have experienced that, it makes great emotional claims on you.”

— Alexander McCall Smith Author of The No.1 Ladies’ Detective Agency Lechwe in the wetlands. Gliding through the Okavango Delta in a mokoro canoe. In awe of the sunrise at Leroo La Tau, the view from your room. Observing the bounty of African wildlife on the water. The jewel-toned Malachite Kingfisher enjoying breakfast. YOUR ITINERARY Optional Pre-Extension to Cape Town Optional Post-Extension to Your Faculty Host Chobe National Park & Victoria Falls Victoria Falls, DAYS 1/2 ~ USA/JOHANNESBURG on the remote Nxaragha Island. Activities here Zimbabwe Michael Weisberg FAIRLAWNS SANDTON HOTEL (Meals Aloft,D) center around mokoro (dugout canoe) rides, boat CHOBE Professor and Chair of Okavango Get set for your adventure as you board your excursions, and walking safaris. See the delta from Philosophy, University of overnight flight to Johannesburg, where you will water level and relax as you glide through quiet, Pennslyvania & Co-director be met and escorted to your hotel. Welcome to reed-lined channels. Pels Fishing Owl and Wattled Camp Moremi Leroo La Tau of the Penn Laboratory for Jo’burg, as the locals say. The vitality of South Crane are observed regularly in the area. In all, more Maun Africa’s largest city is reflected in the gleaming than 600 species reside within the 7000 square Understanding Science facades of abstract modernist skyscrapers and miles of islands, marshes, flood plains, and channels the mercurial flow of its financial center. Gold was of which the Okavango is comprised. Feel the beat Dr. Weisberg is a discovered in the adjacent Witwatersrand area of Africa beneath your feet on a walking safari, and philosopher of science in 1886. Its nickname, “the Rand” later became take a boat through the reeds to spot elephant, red CENTRAL KALAHARI GAME RESERVE whose work focuses on methodological the name of South Africa’s official currency. lechwe, zebra, wildebeest, giraffe, baboon, monkey, Pre-Tour Extension issues in biology, chemistry, and the social You will be staying at The Fairlawns Boutique warthog, and buffalo, along with major predators to Cape Town sciences, and also the public understanding of Hotel & Spa situated in the heart of Sandton, the such as lion, leopard, and hyena. If you are lucky, KALAHARI exclusive residential and business area north of spot the elusive sitatunga antelope which have been DESERT Maun science. Much of Dr. Weisberg’s recent work Johannesburg. known to sleep in the water, with only their nostrils BOTSWANA has focused on biological education beyond resting above the water’s surface. the classroom from alumni travel to working Your adventure begins with a delightful retreat in Continue your adventure to Chobe National Park in DAY 3 ~ CRADLE OF HUMANKIND Johannesburg with indigenous children in the Galápagos Cape Town, one of the loveliest cities in the world. Botswana, home to some of the largest elephant FAIRLAWNS SANDTON HOTEL (B,L) DAYS 9/10 ~ MAUN/OKAVANGO DELTA Destination archipelago. He believes that the best way Today’s drive takes you to the Cradle of Humankind CAMP MOREMI (B,L,D Daily) View Table Mountain and take the coastal route herds on the continent. Stay at Chobe Game Entry/Departure Light Aircraft to learn about conservation, ecology, and World Heritage Site, where research has been Fly to the elegant Camp Moremi, shaded from the to the Cape of Good Hope to discover charming Lodge in the heart of the park and be pampered Post-Extension evolution is to get up close and personal carried out at 13 fossil sites, 7 of which have yielded African sun by a forest of ancient ebony trees. You’ll seaside towns, spectacular wildlife, and the comical with superb service and cuisine. Then, head to Inbound Flight Cape Town hominid remains. The Sterkfontein Caves, which be thrilled by the excitement of tracking animals African penguins at Boulders Beach. Tour the brilliant Zimbabwe for the idyllic experience of Victoria Pre-Extension with diverse wildlife and ecosystems be it in have produced the most complete skeleton of in open 4X4 vehicles and boating up channels and Kirstenbosch Botanical Gardens, and spend a day Falls. This incredible spectacle — “The Smoke That Philadelphia, South America, or Africa. a 3.3 million year old Australopithecine, is a tour across lagoons, all the while viewing the goings on of in the famed Boland Valley wine region. Visit the Thunders,” as it is known to locals — is the world’s highlight. the delta residents. Moremi Game Reserve supports settlement of Khayelitsha with a township guide, and largest waterfall. Enjoy a sundowner cruise on the For More Information or Reservations the most diverse habitat and animal populations get an eye-opening historical tour of Robben Island. Zambezi River and visit a rural village to experience DAYS 4/5/6 ~ MAKGADIKGADI/NXAI PANS/ in Botswana, with possible sightings of wild dog, Kathy Pluas at Classic Escapes age-old traditions. KHUMAGA VILLAGE/MAUN cheetah, and leopard being highlights. Resident 800.627.1244 LEROO LA TAU (B,L,D Daily) species include lion, elephant, buffalo, hippo, giraffe, Fly to Maun and board a light aircraft to Leroo La hyena, zebra, kudu, lechwe, tsessebe, and Sable and Your Journey Costs Your Extensions Costs [email protected] Tau at the edge of Makgadikgadi Pans National Roan antelope. July 19 to 30, 2018 Cape Town – Departs July 15, 2018 Park, named for ancient Lake Makgadikadi, prices per person prices per person Conditions of Travel which disappeared thousands of years ago. What DAYS 11/12 ~ MAUN/JOHANNESBURG/USA remains is a collection of salt pans that cover (B, Meals Aloft) • $8,695 land and air between camps in Africa, • $2,795 double occupancy. HOW TO BOOK: Fill out the reservation form and whatsoever arising from any cause whatsoever double occupancy. send it, along with the relevant deposit as shown, and without restricting the generality of the approximately 6,200 square miles due south of the Enjoy a last wildlife run this morning and a hearty • $995 single supplement. to: Classic Escapes, 58-25 Queens Blvd. Woodside, aforegoing shall particularly not be responsible for Okavango Delta. The camp is situated on the banks breakfast before flying back to Johannesburg via • $2,995 single supplement. NY 11377. Upon receipt of your signed reservation loss or damage arising from any errors or omissions Victoria Falls – Returns August 3, 2018 form and deposit, we will, subject to availability, contained in its brochure or other literature, loss or of the Boteti River and commands superb views. Maun where you connect with your overnight • $2,690 estimated international airfare from Next day, drive to Nxai Pan National Park. These flight to the U.S.A., bringing home with you the prices per person reserve your spot on the tour. You may consider damage caused by delays, sickness, theft, injury, or Philadelphia, including airline taxes and fuel your booking confirmed when you receive a death. In addition the Company shall have the right pans transform during the rainy season between memories of all the wonderful sights of Southern surcharges. Other departure cities available • $3,695 land only. confirmation notice and invoice from us. at any time at its discretion to cancel any trip or the July and October, when they fill with water and Africa. upon request; prices quoted at time of request. • $1,395 single supplement. remainder thereof or make any alteration in route, their stark whiteness becomes lush greenery. Year RATES: Rates are based on the minimum number accommodation, price or other details and, in the round, small populations of springbok, giraffe, and of guests outlined in this document, plus airfare event of any trip being rendered impossible, illegal gemsbok can be found, but during the wet season, costs and other factors and are subject to change. or inadvisable by weather, strike, war, government Your Journey Includes Though it is rare for Classic Escapes to make a price or interference or any other cause whatsoever, their numbers increase significantly, and herds of adjustment after promotion of an itinerary, we the extra expenses incurred as a result thereof zebra and wildebeest arrive bringing with them • Roundtrip flight between Johannesburg and Maun. • Laundry and all local beverages during safari in do reserve the right to assess a surcharge if the shall be the responsibility of the passenger. The Company may at its discretion and without liability opportunistic predators such as hyena and lion. • All flights between the camps. Botswana except for Champagne and imported minimum is not met, or if increases are forced upon Visit Baines Baobabs, an oasis of venerable baobab us by airlines or other partners. or cost to itself at any time cancel or terminate the • Flights between Cape Town and Johannesburg on spirits. guest’s booking and in particular without limiting trees. These “upside down” giants are now part the generality of the aforegoing it shall be entitled the pre-extension. • Complimentary bottled water in vehicles INSURANCE: It is a condition of booking, that the of a protected national monument, providing sole responsibility lies with the guest to ensure to do so in the event of the illness or the illegal or a shady vantage point from which to view the • Flight between Victoria Falls and Johannesburg on throughout. that they carry the correct comprehensive travel incompatible behavior of the guest, who shall in desolate beauty of the Kudiakam Pan. On your and medical insurance to cover themselves, as such circumstances not be entitled to any refund. the post-extension. • All applicable hotel and lodge taxes and gratuities well as any dependents/traveling companions last day, drive to the nearby Khumaga Village for • Superior accommodations throughout as indicated for baggage handling. for the duration of their trip. Classic Escapes and CANCELLATIONS: Cancellations are only effective an enlightening cultural experience. An open-air the University of Pennsylvania, including their on receipt of written notification. The following dinner with traditional storytelling will bookend Caves Of Cradle Of Humankind or similar. • All park entry fees and sightseeing as specified. representatives, employees and agents will take per person fees are applicable on this tour: your day. • All meals while on safari. Other meals as specified in • Gratuities to drivers and other conveyance no responsibility for any costs, losses incurred or • Up to April 18, 2018, $300 handling fee, suffered by the guest, or guest’s dependents or plus $250 non-refundable deposits given to Did you know ... itinerary. attendants. traveling companions. overseas suppliers. DAYS 7/8 ~ OKAVANGO DELTA Batswana is the plural term for people • All wildlife viewing by private 4X4 open vehicles, • Complimentary baggage tags and passport wallet. • April 19 to May 5, 2018, deposit is forfeited. CAMP OKAVANGO (B,L,D Daily) RESPONSIBILITIES: Neither Classic Escapes (the • May 6 to May 20, 2018, less 75% of tour cost on driven by professional driver/guides. • Complimentary Emergency Evacuation Insurance. Fly to one of the world’s most distinctive regions who live in Botswana. The singular Company), the University of Pennsylvania, nor any both the main trip and the extension. • After May 20, 2018, no refund is possible. and largest inland water systems, the Okavango • Professional guide will accompany the group with a person or agent acting for, through, or on behalf of term is Motswana. the Company shall be liable for any loss or damage These cancellation fees are also in addition to Delta and to the exceptional Camp Okavango minimum of 10 travelers. any imposed by airlines.

Name on Card ______Card Number ______EXP_____CVN____

NAME (as it appears on passport): o Mr. o Mrs. o Ms.______

NAME FOR NAME BADGE IF DIFFERENT FROM ABOVE: 1)______

2)______

STREET ADDRESS: ______

CITY:______STATE:______ZIP:______

PHONE NUMBERS: HOME: ( )______OFFICE: ( )______

MOBILE: ( )______FAX: ( )______

Name on Card ______Card Number ______EXP_____CVN____

NAME (as it appears on passport): o Mr. o Mrs. o Ms.______

NAME FOR NAME BADGE IF DIFFERENT FROM ABOVE: 1)______

2)______

STREET ADDRESS: ______

CITY:______STATE:______ZIP:______

PHONE NUMBERS: HOME: ( )______OFFICE: ( )______

MOBILE: ( )______FAX: ( )______