Inschrijfformulier

8-daagse tourtocht noorwegen

Wij gaan mee, vertrekken op 15 juli 2012

Approximate english Translation for information only – please complete Dutch Original

Mr / Mrs : / First Name :
Surname
Nationality / Birthdate
Passport number
Address
Postcode / City
Landline / Mobile :
Emergency Tel No :
Email address
MMRC Numner

2e PERSOON De heer / Mevrouw *

Mr / Mrs / First Name :
Surname :
Nationality : / Birth date:
Passport Number :
Would you like a :- / Ascending travel / 2e PERSOON
- Ascending Warranty Insurance Cancellation / Yes/ No * / Yes/ No *
- Continuous Warranty Insurance / Yes/ No * / Yes/ No *
¹ Insured amount / € 1.500,00 / € 3.500,00* / € 1.500,00 / € 3.500,00*
- Ascending Insurance / Yes/ No * / Yes/ No *
² Geneeskundige kosten meeverzekeren / Yes/ No * / Yes/ No *
- Continuous Insurance** / Yes/ No * / Yes/ No *
³ Insure Medical costs / Yes/ No * / Yes/ No *
** Account Number for Direct Debit :
Room with seperate beds / Yes/ No *
Allergy room [?] : / Yes/ No *
Fare Per person / € 995,00
Extra’s per persoon / - 1-persoonskamer/1-persoonsbinnenhut à € 230,00 / Desired ? Yes / No?
- 1-persoonsbuitenhut (tarief op aanvraag) / Desired ? Yes / No?
- 2-persoonsbuitenhut à € 15,00 / Desired ? Yes / No?

Vehicle Data MAZDA MX-5

Mark : / Type / Year : / Reg No :
Lengte (incl. Towing etc.) (cm) / Height : (cm)* / Width : (cm)*

* Note: If the above dimensions of the vehicle correctly, this can cause problems at embarkation.
It is important that exact dimensions are passed.

NB Any suggestions or wishes you can on the back of this form

* Delete as applicable. Send, fax or e-mail to:

Miata MX-5 Roadster Club * Putsesteenweg 197 * B-2820 Bonheiden

TEL 015/27.89.86 GSM 0475/72.01.78 FAX 015/33.65.09

I pay a deposit of € 50.00 per person to reserve my place.

Payment by: BE09 7450 2671 2657 EUR

The MMRC will form at reception (also) directly through to Old Timers Scandinavian Tours
Rotterdamseweg 191 - 3332 AH Zwijndrecht - Netherlands

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Datum Handtekening

By placing your signature, you agree to the booking conditions of the ANVR.
These conditions can be found on the website. A printed version can be sent on request.