PBCC Tour Information

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* 1. First Name, exactly as it appears on passport. Please type in ALL CAPS. If you do not have a passport yet, please enter your first name exactly as you will/have entered it on the passport application.

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* 2. Middle Name or Initial, exactly as it appears on passport (or blank if no middle name/initial appears on passport). Again, ALL CAPS.

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* 3. Last Name, exactly as on passport. Again, ALL CAPS.

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* 4. Passport Number. If you don't have it yet, or needs to be renewed, please specify that here.

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* 5. Date of Issue of Passport

Date / Time

Date

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* 6. Expiration Date of Passport

Date / Time

Date

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* 7. Place of Birth (as listed on passport, ALL CAPS)

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* 8. Place where passport was issued (most U.S. passports say "UNITED STATES DEPARTMENT OF STATE")

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* 9. Date of Birth

Date / Time

Date

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* 10. Nationality (as listed on passport)

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* 11. Other credential information (for those who do not have a US Passport, enter your greencard or other information here)

Name as appears exactly on greencard or other card

Number

Issue Date

Expiration Date

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* 12. Home Address: Street

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* 13. City

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* 14. State

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* 15. Zip Code

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* 16. Primary E-mail. (Students should list parent e-mail here)

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* 17. Emergency Contact Name

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* 18. Emergency Contact Relationship

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* 19. Emergency Contact Phone Number

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* 20. Emergency Contact E-mail (this can be the same as above)

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* 21. Select the pet animal allergies you have (for home-stay purposes)

Dog

Cat

Bird

All animals with fur

NONE

Other (please specify)

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* 22. Do you have asthma or any problems with smoke (for home-stay and hotel purposes)

Yes

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* 23. Food allergy or restrictions. Select the food(s) you cannot eat. This is only for food allergies and dietary restrictions - not for food preferences or dislikes.

I don't eat any animal meat or products ("I'm a vegan").

I don't eat any animal meat ("I'm a vegetarian").

I don't eat pork (religious/social reasons).

I don't eat any shellfish (religious/social reasons).

I can't eat any shellfish (allergy).

I can't eat peanuts (allergy).

I can't eat tree nuts (allergy).

I can't eat eggs (allergy).

I can't eat milk/milk products (lactose intolerant).

I can't eat milk/milk products (dairy allergy).

I can't eat soy (allergy).

I CAN EAT ANYTHING!

Other (please specify)

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* 24. Food allergy comments. Please comment below if any of your answers above require explanation

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* 25. Other allergies (pollen, penicillin, etc.). You will also be filling out a more complete medical fact sheet later, but we need general allergy information at this point.

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* 26. If you plan on arriving at our destination earlier or staying later and therefore need a different flight schedule than the group, please explain here:

Within a week of submitting this survey (press "SUBMIT" below), you will receive an invoice. Once you respond to the invoice by paying the deposit (through NetSuite or in the office), you will then have reserved your spot for tour.