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12110
Slauson Ave, Suite #3
Santa Fe Springs, CA 90670
Telephone: (562) 698-7800
Fax: (562) 698-7297
e-mail: cuba@cielomartravel.com
RESERVATION
FORM
Departing from:
_______ Miami _______Tijuana
______Cancun
Departure Date: _________ Return Date:
___________ Adult/Child: ___________
NAME (as shown on Passport): __________________________________________
Address:
_________________________________________________________
City:
_____________________________ State:
_______ Zip Code: __________
Daytime Phone:
_________________
Evening Phone: _____________________
E-Mail Address:
__________________________________________________________________
Passport
# _________________________ Expiration Date:
_____________________________
Country of Issue:
_____________________Mother’s Maiden Name: _______________________
Date of Birth:
________________________Place of Birth: ______________________________
Citizenship:______________________________Alien # if Resident
____________________________
Type
of License authorizing travel to Cuba:
Specific License #
___________________________________________________
General License
(specify professional field)
_______________________________
Date: ________ Signature:
____________________________________________
( Please print and fax or mail form along with a copy of
your passport.)
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