Montgomery College Program to

Senegal and Gambia, Africa
December 28, 2009—January 10, 2010

APPLICATION FORM
Please mail this form along with a check by June 30, 2009,
in the amount (deposit) of $200 payable to:

Edu Trips
P.O. Box 19
Orangeburg, NY 10962

Contact Information: Tel: 1-866-824-2266 x 128

Passport Name ___________________________________________________
                                                First                                                      Last
Your Address _________________________________________________________

City ________________________            State ____________            Zip _____________

Phone _____________________            _________________            __________________
                       Home                                                            Work                                                         Cell

Email Address ____________________________________________________

Seating Preference on Flight:                        Aisle ___            Window ___
(This preference is not guaranteed, but we will do our best to accommodate you)

Special Meal Request _______________________________________________

In addition to providing this “Application” form, I have read and accept the conditions of the “Participant Amenities, Conditions and Payment” form. I understand that a deposit of $200.00 is due June 30, 2009. A second payment of $1,000.00 is due July 30, 2009, and a final payment of the remaining balance is due September 30, 2009. Payment may be made by check.

Print Full Name _____________________________________________________

Legal Signature ______________________________________________________

Date: ___________________________