FOR OFFICE USE ONLY

FOR OFFICE USE ONLY Dale received Date dole 'esti specialist 13.s el-IARTED OUrpo s SAFARI & TRAVEL CO. PERSONAL INFORMATION FORM PERSONAL INFORMATION PASSPORT INFORMATION Name (as appears en yew passport) Passport Number Mailing Address Nationality/Citizenship City Lp Date of Issue Date of Expiration Home Telephone Fax: EMERGENCY CONTACT INFORMATION Occupation Name Business Telephone ext. Relationship Business Fax Telephone Email Address Address Height Weight Age Birthdate M/F City Zip Please describe your Health and Medical history: Any other medical conditions we should be aware of: Allergies or dietary• restrictions (vegetarian?): Please list any alcoholic preferences (local beer, wine, domestic spirits). Please note that we will try our best to provide your drink of choice. Describe the nature and extent of your camping, hiking, horseback riding, or other outdoor experience: Please list any special occasions while on your trip: DOCTOR INFORMATION Name Address: Telephone: City: Zip: Uncharted Outposts I p: 505.795.7710 I I: 505.795.7714 I EFTA00602050