Student Name_________________________________________________D.O.B._________________

Guest Name (if any)________________________________________D.O.B._______________

Street Address_________________________________________________________________

City_________________________________  State__________  Zip_____________________

Home Phone___________________________  Work Phone____________________________

Student SS#___________________________  Cruise Dates____________________________

RE License Number    SP / BK ____________________  Renewal Date___________________
                                  (circle one)
   

Note: Prices include cruise, course fee, course materials, taxes and government fees. Pre-paid gratuities and optional insurance not included. 

METHOD OF PAYMENT (check one)   �  CASH    �  CHECK    �  VISA    �  MC

    For Credit Card Payments:  Name on Card:______________________________________

                                        Card Number:_______________________________________

                                                  Expiration Date:____________  Last 3 Digits on Back:______

                                                  Signature:__________________________________________

TOTAL AMOUNT PAID $_______________

�  I am paying for two people
�  I have added $59 per person for the optional insurance
�  I have added $50 per person for pre-paid gratuities

ROOM INFORMATION

�  I plan to bring my own roommate named above as "guest"
�  I plan to room with a licensee who will register separately
    Name_______________________________________
�  I will need help finding a roommate


IMPORTANT NOTICE

-The cruise line requires you to use your legal name and correct birth date when registering.
-Effective Jan, 2007 ALL PASSENGERS must bring a valid passport to board the ship.