Christian Life Movement - Denver, CO & Regina Tours, New York, NY

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THIS TRIP HAS BEEN CANCELLED

UNTIL NEXT YEAR

Enclosed is my deposit for: "10 Day Holy Land Pilgrimage –  CLM/Chism"

Booking Number: 21161 (Please write this Booking Number on the Memo Line of Your Check)

o     $459 ($250 + $209 insurance) per person

o     $250 (if insurance is declined) per person

o     Full Payment:   $__________ X _____ people = $ ____________

What is your affiliation with Christian Life Movement?  Choose all that apply.

□ CLM Colorado   □ CLM USA-other                          □ Fraternas   □ Sodalits   □ Family   □ Friend   □ Member

□ None of the above     □ My CLM contact is_____________________.

Credit Card # (Amex / Visa / Master Card): _______________________________________________________

Expiration Date: _____________________ * Sec Code  _____________(*3 or 4 digit number on back of cr. card)

Credit Card holder Signature:__________________________________________________________________

The name of the merchant on your credit card statement will be “Group IST.” Group IST does business as “Regina Tours.”

Clearly Print Name as it appears in your passport: (Last, First):

__________________________________________________________________________________________

US Passport #: _____________________ Expiration Date: ____________

(Passport must not expire for 6 mos. after return)

Home Address: _________________________________________________

City _________________________________ State _______ Zip ___________

Home Phone: _________________ Business Phone: _________________ Cell Phone: _________________

Email:__________________________________________________________

Rooming With: __________________________________________  Single Room (additional Cost): o Yes  o No

Smoking: o Yes     o No     

Emergency Contact Information Below:

Name: ______________________________ Phone: ________________Relationship______________________

 Enrollment in and payment for the tour constitutes your acceptance of the program conditions.

Make check payable to: “Regina Tours”

write your Booking Number (see above) on the Memo Line of Your Check

Mail payment to:

Regina Tours, Att. CLM Holy Land Pilgrimage

494 Eighth Avenue, 22^nd Floor

New York, NY 1000