CE National 2012 Registration Form

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How many slots would you like to reserve for this trip?

Please enter a value greater than or equal to 1.
Legal Name

As it appears on your passport
Date of Birth

MM

DD

YYYY
Passport #
Exp. Date

MM

DD

YYYY
Spouse's Name (if traveling)

As it appears on his/her passport
Date of Birth

MM

DD

YYYY
Passport #
Exp. Date

MM

DD

YYYY
Address

Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code

Country
Cell Phone
Home Phone
Email
Rooming Preferrence
- Single occupancy ($520 additional charge)
- Double occupancy
Name of Preferred Roomate

If unspecified, we will match roommates when possible.
Flight Preferrence
- Trans-Atlantic only (included in price)
- Domestic + Trans-Atlantic (additional domestic fares will be added to price)
- Land only ($2395 – you will be responsible for your own air and transfers)
The trans-Atlantic flight is included in the $3695 price.
Preferred Local Airport

You will depart from here to the east coast gateway. Reduced rate domestic addons will be used whenever possible.
I understand that my slot(s) will not be reserved until the $300 deposit per person has been recieved. I have read the Program Conditions and understand the cancellation policy. Full payment is due by August 1, 2012.
Digtal Signature

By typing you name you are accepting responsibility for the statement above.
Date
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