Bimini June 2002

REGISTRATION FORM (Print this and mail it)

Passport Name:_________________________________
Address:_______________________________________
_______________________________________________
Phone Home:___________________________________
PhoneWork:____________________________________
Date of Birth:___________________________________
Passport: # ___________________Citizenship:_______
Roommate if known:____________________________
I heard about this journey from:_____________________

Please charge my Credit Card
Name:________________________________________
Credit Card:___________________________________
Exp. Date:_____________________________________
Print name on the card:____________________________
____________________________________________
Credit card Customer Signature