1040 Moss Street Victoria BC V8V 4P1 aggv.ca/events/art-tours/japan Curator-Led Tour to Japan - November 1-13, 2015 Please complete and return to the AGGV at the above address, by July 15, 2015 by cheque to AGGV or by credit card PERSONAL INFORMATION ______________________________________________________________________________ Last Name First Name Middle Name □ Male □ Female ______________________________________________________________________________________________________________ Street Address ___________________________________________________________________________________________ City Province ________________ Postal Code ______________________ ________________________ ____________________________________________________________ Home Telephone Number Alternate Telephone Number E-Mail Address _________________ Date of Birth ______________________________ Passport Country _____________________ Passport Number _______________________________ Emergency Contact (Name and phone number):________________________________________________________________________ _______________________________________________________________________________________________________________ □ window+next □ Twin beds INSURANCE: □ aisle+next □ Queen □ aisle+aisle □ Single □ Double, rooming with ________________________________ Tour I have the following insurance coverage: Name of Insurer _________________________________________________________________________________________________ Policy No. ____________________________ Expiry Date: _______________ Insurance contact Telephone: ________________________ ___________________ Date _______________________________________________ Signature Tour organized by: Vision Travel Services: Tour Coordinator: June Sohuus sohuus@shaw.ca 250-478-9515 250-412-1876