XODUSINT
* = Required Field

NOTE: Please enter your name as it appears on your passport
Please check one: Dr.   Mr.   Mrs.   Miss   Rev Occupation:           
* First Name: * Last Name:            
* Address 1:
   Address 2:
* City:    * State:           * Zip:   
Date of Birth:       Nationality:             
City of Birth:       State of Birth:          
* Daytime Phone:       Evening Phone:       
* Email:             Roommate:    
Tour Number:             Destination:    

PASSPORT INFORMATION
Passport Number: Place Issued:
Date Issued: Expiration Date:

HEALTH AND DIETARY NEEDS
I have the following condition(s): (Please Check)
Allergy to horse serum:
Allergy to bee stings:
Allergy to tetenus shots:
Allergy to some foods: Please List:
Epileptic Seizures: Please Describe:
Heath/Respiratory/Other: Please Describe:
I require a special diet.
(If vegetarian, please be specific)		 Please Describe:
Are there any other health issues we should know about?
Name of Physician:       Physician Emergency Phone:    
Physician's Address:
City:    State:           Zip:   
Health Insurance Company:       Policy Number:        Blood Type:   

ACTIVITIES AND INTERESTS
Please check the areas of interest. TOUR OPTIONS
   History

   Bird Watching

   Observing Wildlife

   Botany

   Photography

   Fishing

   Shopping

   General Nature Study

   Studying Local Cultures

   Hiking

Other   

If you are interested in extending your tour,
please give us details of what you would like to plan:

Please give number of days you would like to extend:

FUTURE TRAVEL

Where are you interested in traveling?

Please give dates:

Number of adults:       Children:   

Type of Acomodations:

EMERGENCY CONTACT
* First Name * Last Name:
* Address:
* City:    * State:           * Zip:   
* Daytime Phone:       Evening Phone:       

DOMESTIC AIRLINE RESERVATIONS
If you are making your own domestic airline reservations, please provide details:
Airline Flight # Date Departure Arrival

African Delegation ONLY

Please choose options and then click on payment link below. Note: On the next page indicate your option and hotel choice, if applicable. If you plan on participating on the cruise on the 9th, please add $49.00 (ZAR367.50) If you have questions, please contact Xodus at travel@xodusint.com.
COST - USDCOST - RAND
Option 1 Summit Conference in Zambia December 8 – 9, 2011 for 2 days only. $250.00 ZAR 1,875.00
Option 2

Two night hotel stay & Summit – only December 8 – 9, 2011

Zambezi Sun Hotel Daily breakfast - 2 nights – No tour participation $680.00 ZAR 5,100.00
Waterfront Hotel Daily breakfast - 2 nights - No tour participation $659.00 ZAR 4,942.50
Protea Hotel Daily breakfast - 2 nights - No tour participation $633.00 ZAR 4,747.50
Option 3

Summit including hotel & and Tours – 4 Nights - December 8 – 9, 2011

Zambezi Sun Hotel Daily breakfast - 4 nights $1365.00 ZAR 10,237.50
      No Tour participation $1265.00 ZAR 9,487.50
Protea Hotel Daily breakfast - 4 nights $1125.00 ZAR 8,437.50
      No tour participation $1030.00 ZAR 7,725.00
Waterfront Hotel Daily breakfast - 4 nights $1063.00 ZAR 7,972.50
      No tour participation $968.00 ZAR 7,260.00

PAYMENT INFORMATION
Please select your method of payment below. If paying by credit card, please include your billing address and phone.
For Credit Card Payments:
   Visa
   MasterCard
   Check/Money Order 		Name on Credit Card:  
Card Number:              
Expiration (MMYY):    
Billing Address:             
Billing Phone Number:  

I am a tour participant traveling with Xodus International Group on to , tour number . I authorize Xodus International Group to charge my credit card in the amount of $.

I prefer to have my documents sent   Regular Mail     UPS     FEDEX

DISCLAIMER
Arrangements for the tour have been made by Xodus International Group Inc., the tour operator. Xodus International Group Inc. has engaged the services of airlines, hotels, transport and sightseeing companies which are not its employees or agents. All tickets and coupons are subject to any and all terms which govern such means of transportation or services as offered and the insurance and acceptance of such tickets and vouchers shall be deemed consent to the further conditions that Xodus International Group shall not become liable or responsible for any loss, injury or damage to or in respect of any person or property.

The tour member specifically waives any claims agains Xodus International Group Inc. for any damage to or loss of property or injury or death of persons due to any act of negligence of any person rendering services or accommodations set forth in the itinerary or substitution of services which in their sole opinion or in the opinion of ground operator or dictated by prevailing circumstances. This is to include a withdrawal of the tour, cancellation of specific members, alterations or accommodations should conditions warrant. All rates are based on tariffs in effect at the time the tour was planned and are subject to change in the event of adjustment therein.

No refund can be made unless agreed upon prior to the departure of the tour. Refunds, if any, are limited to the amounts recovered from the hotels and operators of services and are payable only when received. We also reserve the right not to accept or continue with a participant who affects the enjoyment or rights of other group members. This agreement is solely between the participant and Xodus International Group Inc.

TRAVEL INSURANCE

Travel Insurance Company:        Phone Number:        Date Issued:   

I have elected not to obtain traveler's insurance. Please check here:   

By submitting this form, I signify that I have read and agreed to the above and to the terms, conditions and cancellation penalties.