Title:

Mr Mrs Ms Dr. Prof.

First Name:

Last Name:

Country of Residence:

Email:

Telephone Number:

Area Code: Number:

Number of Adults:

n/a 1 2 3 4 5 6 7 8 9 10 11+

Number of Children:

n/a 1 2 3 4

Lodge Preference

Lentaba Lodge - no children allowed Tree Tops - no children allowed Mark's Camp - child friendly

Unsure of Arrival and Departure?

No Yes

Arrival Date:

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2010 2011

Departure Date:

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2010 2011 2012

Do you need a transfer between P.E. and Lalibela?

No Yes

Is this a:

Request
         or an
Enquiry

Enquiry/Request or Special Requirements:

Children?
_{Note: If you are travelling with children please add to your enquiry any extra information such as: number of children and ages. Mark's Camp Only}