Sign up form for May Israel trip

Ezra – Habonim, The Niles Township Jewish Congregation
MISSION TO ISRAEL
May 18, 2008 (send in with $500 per person deposit to EHNTJC -$520 if by credit)

Passport Information: (Please include Mr., Mrs. Or other titles as Dr., Rabbi, etc.)
1. Name (as it appears on your passport) _________________________________ Nickname _______________
Birth date: ______________________________ Passport # _______________________________________________
(Month/Day/Year)
Country of Origin ______________________________________________ Expiration Date __________________
2. Name (as it appears on your passport) _________________________________ Nickname ________________________
Birth date: ______________________________ Passport # _______________________________________________
(Month/Day/Year)
Country of Origin ____________________________________________ Expiration Date __________________
Please attach a clear photocopy of your passport identification page. Passport should be valid for a minimum of 6 months after planned return. If you need a renewed passport, please contact the U.S. Passport office for information.

Mailing Address/ Telephone:
Street ______________________________________________________ Apt # __________________
City ______________________________ State ________________________Zip _______________________________
Home Telephone ( ) _________________________________________ Work ( ) ______________________
Fax ( ) _________________________ E- Mail Address _______________________________________________

Air Travel:
I wish to extend to Eilat _____ Yes _____ No

I/We would like to extend my stay in Israel until _______________________________________

I/We will need additional hotel arrangements _______________________________________

Special Arrangements:

Kosher

Other Dietary Request (plane service only) ____________________________________________
On the plane I/We would like to sit next to (subject to availability) ________________________

Single Room ($ __________ additional cost) Assign me a roommate
I would like to room with ___________________________________________________________

(If we are unable to provide a roommate for you, the single supplement charge will apply. Roommates will be assigned on a first come first serve basis)

Insurance: In order to cover any pre-existing conditions – Anyone who wish to have travel insurance, the travel agent needs to know within 2 to 3 days of their deposit date. The insurance company will cover pre-existing conditions if insurance is bought within 13 days of deposit date.