First Name

Middle Name

Last Name

Mother's Maiden Name

Your Email (

Phone

Departure Date

Return Date

Passport Number

Passport Expiration Date

Address

Occupation

Nationality

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

How many times have you traveled to Cuba?

If born in Cuba, when did you leave?

Cuban Passport Number (if applicable)

Cuban Passport Expiration Date

When was the last time you traveled to Cuba?

Are you traveling to Cuba on a Copperbridge Foundation People-to-People program?
YesNoDon't Know
If not, what is your reason for traveling to Cuba?

Name of Accommodations

Select one:
Own RoomShared Room (shared bed)Shared Room (separate beds)d
If shared room, name of roommate:

Select one:
Standard RoomExecutive RoomJunior SuiteSenior Suite
Special Needs/ Requests:

Allergies:

I, , have filled this application out to the best of my knowledge.
I acknowledge that I am going to Cuba for under one of the 12 permitted categories.
It is my responsibility to ensure I am traveling legally to Cuba in accordance with OFAC regulations.
It has been made clear to me by Gypsy Travel Service. I will not hold them accountable if I am found to be in violation of the law.
Type full name to sign:

Subject

Your Message

PHONE

PHONE
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Flight Price: The flight price of $ represents your cost for a flight that departs from to on _____________ and returns from ______________________ to _______________ on _________________.