COMPLETE ONE FORM PER CABIN

FAX TO: KIQ TOURS FAX NUMBER (617) 298-7349

RE: AQUA BOOGIE CONFIRMATION #______________________(IF APPICIABLE)

NAME _______________________________________ TEL #:____________________

ADDRESS______________________________________________________________

CITY__________________________ STATE__________ ZIP CODE_______________

E-MAIL ADDRESS_______________________________________________________

# OF GUEST IN CABIN (CIRCLE ONE) 1 2 3 4

(METHOD OF PAYMENT) VISA MASTERCARD DISCOVER NOVUS

CREDIT CARD HOLDERS NAME___________________________________________

ACCOUNT #:_________________________________ EXP. DATE__________

3 Digit Cust. (On Back Visa/MC Card) #_________, 4 Digit # on front (Amex)__________

GUEST #1 _________________________________ INSURANCE YES_____ NO_____

GUEST #2 _________________________________ INSURANCE YES_____ NO_____

GUEST #3 _________________________________ INSURANCE YES_____ NO_____

GUEST #4 _________________________________ INSURANCE YES_____ NO_____

INITIAL PAYMENT AMOUNT: $100.00 MIN. PER PERSON X _____= $____________

IF PAYMENT AMOUNT ON EXISTING RESERVATION: $______________________

SIGNATURE._________________________________ DATE_____________________