Legal Name
 Address       
 Apt #            
 City              
 State               Zip Code

  Email Address 
  Home Phone   
  Work Phone    
  Fax Number    
  Gender            
  Date of Birth    
 

 Need a roommate          Yes   No
 Do you smoke                 Yes  No 
 Are you a U.S. citizen     Yes  No 

Would you like an airfare quotation?  Yes    No  If so from what city  

Note: Prices do not include airfare to Miami

3-Nights Jewish Singles Chanukah Cruise: 12/19/08 - 12/22/08

NOTE:  Cruise Line reserves the right to increase published rates and air fare supplements without prior notice. However, fully paid or deposited guest will be protected, except for fuel surcharges, government taxes, other surcharges and changes to deposit, payment and cancellation terms, conditions which are subject to change without notice.

How would  you like to pay for this fabulous singles cruise vacation.

If by credit card please fill in the following information as it appears on the card.

Name on Credit Card

Credit Card Number

Expiration Date

Cardholder's Billing Address

Street Address:      City:       State:        Zip: 

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