Planned Departure Date

If you are planning on departing for Cambodia earlier, please advise. If you are unsure, select the tour staring date and update us later.

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Room Share *

Twin Share

Single Supplement (additional fee)

Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of Kin Name *

First Name

Last Name

Next of Kin Phone Number *

Country

(###)

###

####

Significant/recurrent illness or hospitalisation *

Yes

No

High Blood Pressure or Heart Condition *

Yes

No

Allergies, reactions to drugs or food *

Yes

No

Regular Medication *

Note: this refers specifically to medically prescribed medications

Yes

No

Asthma, diabetes or epilepsy *

Yes

No

*

I confirm that I have entered my name EXACTLY as it appears on my passport

*

I agree to all terms and conditions as outlined in the booking conditions.