ANDESCAPE - TRIP APPLICATION FORM      

EBERHARD  599  -  PUERTO NATALES  -  CHILE

phone – fax  :   56 ( 61 )  412592   /   412877

e-mail :  andescape@terra.cl    /     www.andescapetour.com

Please write in printing all the information of the form and mail it together with a Proof of Deposit at our account, to ANDESCAPE Ltda. at the address given above, or to your local Operator.

If you want us to secure your Firm Booking  we must receive the  Proof of Deposit by Fax, otherwise you will not be confirmed on the trip.

Each participant must fill a separate application, though you may deposit the amount for the a whole group.
     andescapetour
List and code of trips (select one)
  		 Departure
 

Final Date
 

 

 

 

 

Personal Information: (privacy only to be manage by our company)
Full Name: last / first / middle
Profession:
 Nationality:
 		Date of Birth:
 
Passport Number:
  		 Place of Issue:
 		 Expiration Date:
 
Address: street / number
 City / State
 		Country:
  
e-mail:
 		 Phone home:
 		Phone ( office)

 

 

Medical Information: (privacy only for medical purposes in case of emergency)
Dietary Restrictions:
  
Allergies I suffer
 		Medicine I am taking now:
  
In case of emergency pleasy Notify (name / address / phone)
  
Insurance Company Name:
 		Emergency Phone:
Policy Number:
  		 Age
  

Gender-M-F

 Heigh(mt)
  		 Weigth(kg)
  

 

  Observations..:
  How did you get to know about us?..

  Andescape Ltda. Eberhard 599, Puerto Natales, CHILE.  Fonofax:  56 ( 61 ) 412592 / 412877  andescape@terra.cl