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