Legal Name:

D.O.B.

Contact Number:        

E-mail:

Nationality (Passport):

Ethnicity:

Occupation:

Destination

(Country, City, State):

Resort: (If Applicable)

Start Date:

End Date:

Duration of Visit:

Expectations:

$200 verification fee required to start intake process for new clients.

 ▢  I am not prepared to pay the verification fee.
▢  I am ready to pay the verification fee. (Payment Details Enclosed)
▢  I am already an established client.

Payment Details:

▢ Cash Enclosed  (Amt $200.00)            

▢ Check   (check #            , Amt $200.00)

Date:

Sign: