Splendid China Highlights Tour Application Form - Sp05

(To be completed and returned to Gary Mahan on or before 22 Jan 05)

(last modified 1/12/05)

Name (print): ___________________________________________________

Last First Middle (full)

(It is essential that the above must be exactly as appears on passport – no nicknames)

Preferred name to be called:___________________________________

Sex: Male Female

Current local Address:

______________________________________________________________________________

St./Apt.

______________________________________________________________________________

City, State, Zip

Permanent Address (if different from above):

______________________________________________________________________________

St./Apt.

______________________________________________________________________________

City, State, Zip

______________________ _______________________ ________________________

Phone (local home) Phone (work) Mobile

_______/_______/__________ _____________/____________

Date of birth (mm/dd./yy) Place of Birth (City, Country)

United Airlines Mileage Plus account number: ______________

Year of study: Frosh Soph Junior Senior Grad Non student

Major/Minor:______________________/____________________

Roommate selected, if any:______________________

If roommate selected, prefer: Two single beds one double bed

All non smoking rooms are to be requested unless informed otherwise. Prefer smoking room: Yes No

Tobacco smoker: Yes No

If is possible to provide transportation to the Pittsburgh airport, would you prefer to provide your own transportation to/from the Pittsburgh airport: Yes No

Medical Info (Allergies, medications, etc.):

Special Dietary Requirements:

Emergency Contact: ____________________________ Phone: ( ) _________________________

Aircraft seating preference: window center aisle don’t care

If an airport other than Pittsburgh is preferred for departure what is it? ________________________________