Passenger Name (as it appears on Passport): ________________________________________________________________________
Address:________________________________________________________________
City:
Home Phone:______________________Bus. Phone:_____________________________
Email:__________________________________________________________________
Enclosed is my Check of $:___________($600.00 per person) Payable to R. Plaszewski
I have read and agree to the terms and conditions outlined in this advertisement:
Signature of Passenger:_____________________________________________________
Please return this form and payment to: R.Plaszewski,