| Personal Information |
1st Applicant |
2nd Applicant (if applicable) |
| First Names |
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| Surname |
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| Home Address |
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| Home Phone |
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| Cell / SA Contact |
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| Email |
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| Nationality |
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| Passport
No. |
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| Passport Issue Date |
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| Passport Expiry Date |
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| Medical Conditions |
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| Dietary Requirements |
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| Who to contact in Emergency |
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| Phone No. |
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| Tour Details |
| Tour Name |
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| Departure Date |
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| Departure Point |
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| Category - Own Bike / Hire Bike / Pillion |
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| Tour Cost (Due 4 weeks before tour) |
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| Single Supplement (If applicable) |
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| Motorcycle Hire |
| Name of Rider |
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| Divers Licence No. |
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| Country of Issue. |
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| Date of Original Issue |
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| Date of Expiry |
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| Total Value of Motorcycle Hire |
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Credit Card Details
(if you want to pay by credit card. Please note our prices are strickly
cash and there is a 5% charge for credit cards) |
| Card Type - AMEX / MASTERCARD / VISA |
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| Card Number |
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| Expiry Date |
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| Name of Card Holder |
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| Last 3 Digits on Back of Card |
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| Amount to Charge |
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| Signature of Card Holder |
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| I have read, understood, and agree to
the
conditions
of booking, motorcycle hire and insurance. I have read, understood
and accept all information on the Go-Mad Enduro web site, particularly
with regard
to acceptance
of risk, type of travel, likely conditions, cancellation and what
is / not included in the tour cost and motorcylce hire. I agree
to pay
the balance no later than 4 weeks before the departure date and am
aware that an additional deposit is due on departure if I hire a
motorcycle hire. I am
aware that the contract including all matter arising from it, is
subject
to South African law and the exclusive jurisdiction of the South
African courts. |
| Signature |
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| Date |
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How did you here of Go-Mad Enduro?
eg.
Advert In (which publication?), Travel Agent (name), I am a previous
passenger, Website, Other please specify: |