FLORIDA COUNCIL OF CHAPTERS CONVENTION 2004

MOAA CRUISE REGISTRATION FORM, MS ZAANDAM

Western Caribbean, Departs Port Canaveral Sat, 3 Apr 2004, Returns Sat, 10 Apr 2004

Please print except for signatures.  Names must be exactly as they appear on your passport.

* Proof of citizenship is mandatory

                                                                                                                                                                                           M/D/Y

1.Nme/Rnk/Svc________________________ * Nationality_______ DoB_________ Gender ___

                                                                                                                                                                                           M/D/Y

2.Nme/Rnk/Svc ________________________ *Nationality ______  DoB ________ Gender ___

(Attach additional page for third and fourth passenger)

Address _______________________ City _________________ State ____  Zip _______

Home Tel Number _______________ E-Mail Address __________________________

Emergency Contact and Phone Number ____________________________________________

Chapter Name ______________________ Cabin Category Preference __________________  

Dinner is 1^st Seating,  Dining Companion(s) _________________________ ________________

Name to be Placed on Nametag 1^st Nme ______________________ 2d ____________________

$350 DEPOSIT ENCLOSED OR TO BE CHARGED TO CREDIT CARD.  Make checks payable to Good Friends Travel Service.  Final payment is due not later then 4 Jan 2004.

                                                                                                                                                    M/Y

Credit Card Company _______ Credit Card Number _______________________Exp _______

Name on Credit Card (Exactly as Shown) ___________________________________

I authorize Good Friends Travel Services, Inc, to use this credit card for the required payments for this cruise.

                                                                        ____________________________

                                                                        Signature of Cardholder

Please provide me with information concerning cancellation and emergency medical insurance.  Yes ___ No ___ Special Request ___________________________________

Mail or FAX this form to:   Good Friends Travel Service                    Tel: 321-777-0130

                                                2328 N A1A                                       Toll Free: 800-407-0099

                                                Indialantic FL 32903                                 AX: 321-777-0132

For Travel Office Use Only

                         Amount                  Date Rec�d            Method of  Pay                      Ck Number

 Deposit   ________    _________   ___________      ________

 Final Payment    ________          _________      ___________              ________