| SOUTH AFRICA TOUR - RESERVATION FORM | ||||||||||
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| Please complete one form per person travelling | ||||||||||
| Name as it appears on your passport: | ||||||||||
| Last name | First name | |||||||||
| Date of birth | ||||||||||
| Passport | US [ ] | Other ____________________________ | ||||||||
| Address | ||||||||||
| Tel No | Fax No | |||||||||
| Work No | ||||||||||
| Dietary requirements: | ||||||||||
| Vegetarian | [ ] | Low Fat [ ] | Other _______________________ | |||||||
| Accomodation | ||||||||||
| Twin [ ] | Double [ ] | Single [ ] |
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Sharing with: _______________________________ |
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| I prefer to pay by: Bank Transfer [ ] Certified Check [ ] Credit Card [ ] | ||||||||||
| Insurance | All inclusive (amounts listed below) | Yes [ ] | Amount: | USD _____________ | ||||||
| Non-Medical Inclusive | Yes [ ] | Amount: | USD _____________ | |||||||
| I Decline insurance | Yes [ ] | Signature____________________________ | ||||||||
| All inclusive insurance: Age | Under 55 | USD 168.00 | ||||||||
| 55 - 59 | USD 192.00 | |||||||||
| 60 - 64 | USD 218.00 | |||||||||
| 65 - 69 | USD 262.00 | |||||||||
| 70 - 74 | USD 364.00 | |||||||||
| 75 - 79 | USD 552.00 | |||||||||
| 80 - 84 | USD 721.00 | |||||||||
| 85 + | USD 1016.00 | |||||||||
| Non-Medical Inclusive insurance:Age | Under 55 | USD 137.00 | ||||||||
| 55 - 59 | USD 149.00 | |||||||||
| 60 - 64 | USD 167.00 | |||||||||
| 65 - 69 | USD 181.00 | |||||||||
| 70 - 74 | USD 204.00 | |||||||||
| 75 - 79 | USD 298.00 | |||||||||
| 80 - 84 | USD 387.00 | |||||||||
| 85 + | USD 505.00 | |||||||||
| All inclusive insurance includes medical (up to USD 15, 500), cancellation, interruption, baggage and flight accident insurance | ||||||||||
| Non-Medical inclusive insurance only includes cancellation, interruption, baggage and flight accident insurance | ||||||||||
| Mail or Fax completed form to: | ||||||||||
| Lion World Tours, 33 Kern Rd | ||||||||||
| Toronto, ON Canada M3B 1S9 | ||||||||||
| Fax (416) 920-9560 Phone (416) 920-5466 | ||||||||||