World Medical Association Associate Members Batumi Trip

World Medical Association Associate Members Batumi Trip
October 27-30, 2019
A. To join this trip, complete this form and send it to agermanashvili@advantourcom as soon as possible but
no later than June 30, 2019.
B. Include a scanned copy of the ID page of each traveler’s passport.
C. Mr. Avtandil Germanashvili will send you a secure link for you to send a non-refundable deposit of $100 per
traveler no later than June 30, 2019. If for any reason the trip is canceled, your payment will be refunded.
1) Traveler’s Full Names
A)________________________________________________________
B)_________________________________________________________
2) Your address ________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
3) Email address _____________________________________________________
4) Mobile phone number _____________________________________________________
5 Emergency contact in your country:
Full name:____________________________________________________
Email: ____________________________________________________
Phone: ____________________________________________________
5) Have you had any operations in the recent past or have life supporting devices/implants (e.g., prosthetic
cardiac valve) or have any special health condition (allergies, asthma, high blood pressure, other?
______________________________________________________________________________
6) Any dietary restrictions? Are you vegetarian/vegan/celiac/lactose intolerance? _____________
7) Bed Request: [ ]One Bed for Two People [ ] Two Single Beds