EmailMe Form - Registration Form | Dr. Charles Mullings

Title

Last Name *

First Name *

Middle Name

Gender *

Male

Female

Passport Number *

Date of Issue *

MM / DD / YYYY

Date of Expiration *

MM / DD / YYYY

Country of Citizenship *

Date of Birth *

MM / DD / YYYY

Are you interested in purchasing Travel Insurance?

Yes

No

Meal on Flight

Regular

Vegetarian

Kosher

Mailing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Please make sure to include your apartment number to guarantee delivery of travel documents.

Phone *

### - ### - ####

Email *

Room Type *

Single Room (for 1 person only = +$TBA)

Double Room (for 2 people only = 1 double bed)

Twin Room (for 2 people only = 2 twin beds)

Triple Room (for 3 people only = 2 twin beds + sofa bed/cot)

If you chose a Double, Twin, or Triple room, please list your roommate(s) name(s) below:

Questions or Comments:

Please Note:

1. Price is based on a minimum of 25 people
2. Please submit a copy of your passport, which must be valid for at least 6 months from the dates of the tour
3. Go Israel NA is obtaining a visa to Jordan for the group. A visa to Israel is not required for U.S. citizens; if you hold a different passport please contact us
4. Airport taxes are subject to change by the airline until ticketing
5. To complete your registration, a non-refundable deposit of $250 per person is required

Mailing address for $250 deposit + passport copy:

Go Israel NA
5003 Westpark Drive #104
North Hollywood, CA 91601

6. To pay your deposit by credit card, please visit our website:

www.GoIsraelNA.com/payment

Please note: all credit/debit card payments are subject to a 3% processing fee (3.5% for American Express and 4% for international transactions).

7. By signing this form you agree to our Terms & Conditions:

www.GoIsraelNA.com/terms

Signature: *

Today's Date *

MM / DD / YYYY