Life by Intent LLC:  Spiritual Journey Application: October 12th - 18th, 2008
Please print clearly as this is needed for your hotel reservations and in case of emergency. 

Full name (as it is on your passport)__________________________________

Mailing Address___________________________________________________

City___________________________State_________________Zip__________

Home Phone (       )_______________      Alt Phone (      )_________________

E-mail__________________________       Marital Status__________________ 

Sex________Age________Height_______Weight ________Citizenship_______

Birthdate (month/day/year)__________________ Birthplace  _______________

Passport Number_________________________Place of Issue ______________

Passport Expiration Date (must be 6 months after trip)____________________

 

In case of Emergency contact: ________________________________________

Address__________________________________________________________

Telephone_____________________________  Relationship_________________

 

Airline Flight Information:

Into Mexico City:      Date    ______________ Arrival Time __________________

Airline and Flight number      __________________________________________

 

Depart Mexico City: Date:    ____________ Departure Time _________________

Airline and Flight Number      __________________________________________

 

Final payment due by October 1st          Fee for Journey:          $1,295.00   

Double occupancy room (Y or N)  Preferred room mate     ___________________

Single Room Supplement   (optional $400.00):                              ___________

$300.00 Deposit required to reserve a space            Total Due:     ____________