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Contact Information

        Mr. Mrs. Miss. Ms.

First Name
Last Name
Street Address
Address (cont.)
Zip/Postal Code
Home Phone
Your Sponsor's E-mail
Your E-mail

Select a Safari that interests you most:

Any other particular Safari not listed above?

Would you prefer to:

Visit one area?	Visit two or more?

Would you like an element of Adventure?

Yes No

If so, which of the following is of interests to you? (Multiples allowed)

White River Rafting
Bungee Jumping
Rock Climbing

Any other that is not listed above?

Which of the following activities interests you?

Bird Watching  
Game Viewing   

Any other activity not listed above?

What would the maximum duration of your Safari be?

Will you be comfortable in a group of strangers?

Yes No

If the above answer is "No", and you prefer an exclusive Safari, how many people would be in your group?

Must the Safari be suitable for children?

Yes No

What type of accommodation would you prefer:

Have you ever been on an African Safari?

Yes No

If so when (approximately) :

-- dd/mm/yy

To which African country?

For what reason?.

What is your age group?

What is your state of health?

Please contact me:

By E-mail
By Phone

I agree by submitting this survey that I may be contacted as indicated above:

I Agree!