Confidential Passenger Information

1. Please provide the following contact information:

   Title
   * First Name
   * Last Name
   Organization
   * Street Address
   Address (cont.)
   * City
   * State/Province
   * Zip/Postal Code
   * Country
   Work Phone
   * Home Phone
   FAX
   E-mail

2. * Requested destination ?   Please Select Florida Keys Bahamas Honeymoon Wedding Private

3. * Total passengers traveling with you ?   Please Select 1 2 3 4 5 6 7 8

4. We offer  8 days and 7 night all inclusive charters crewed charters. Please indicate the date of arrival and date of checkout.

   *Arrival      Month    Please Select January February March April May June July August September October November December      * Day    Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31      * Year    Please Select 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

   *Checkout   Month    Please Select January February March April May June July August September October November December      * Day    Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     * Year    Please Select 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

5. All foreign nationals are required to fully complete this section. For US Citizens visiting the Bahamas a passport is not required but is recommended.

   * Country of Birth
   Name as it appears on Passport
   Passport Number
   * Country of citizenship
   Passport Expiration Date

   Visa - Country

   Visa Expiration Date

6. * Do you have any medical conditions ?   Please Select Yes No

   If yes please describe

7. * Do you have any dietary restrictions ?   Please Select No Yes

   If yes please describe

8. * Please describe yourself:

   * Date of Birth	* Month (2 digit)      * Day (2 digit)     * Year(4 digit)
   * Age
   *  Marital status	Please Select Married Single
   * Sex	Please Select Male Female
   * Height	* feet       * inches
   * Weight	*   lbs

9.  * Were you referred by Travel Agent or did you contact us directly ?   Please Select Direct contact Orca Sailing Toto Tours

8. * What best describes your career ?      Please Select Business owner Coporate Executive Education Financial Services Government Homemaker Legal Managment Medical Retired Sales - Marketing Technology Trades

9. * Do you have a Dive Log ?       Please Select Yes No

10. * Are you a certified diver ?        Please Select Yes No

11. * What is your certification level ?       Please Select Not Certified Basic Open Water Advenced Open Water Rescue Diver Dive Master Instructor

12. * Number of logged dives in the last year ?       Please Select None 1-10 10-20 20-50 50-100

13. Average depth of dives in the last year ?       Please Select None 0-25 feet 25-50 feet 50-75 feet 75-100 feet Over 100 feet
     

14. Please provide the following Dive Certification information.

    (required only if you will be scuba diving.)

    Certifying Agency      

    Certification Number  

15. * Are you a member of Divers Alert Network "DAN" ?  Please Select Yes No

           If yes please date of expiration 

           If yes DAN policy number 

16. * Have you ever used a Surface Air Supply "SAS" system for diving ?  Please Select Yes No

       (Diving certification is not required. We will provide training and instructions.)

17. * Please select any activities that you may be interested in:

    * Scuba Diving	Please Select Yes No Maybe
    * Snorkeling	Please Select Yes No Maybe
    * Sport Fishing	Please Select Yes No Maybe
    * Beach Combing	Please Select Yes No Maybe
    * Exploring Spanish galleons	Please Select Yes No Maybe
    * Underwater Photography	Please Select Yes No Maybe
    * Sun Bathing	Please Select Yes No Maybe
    * Clothing optional	Please Select Yes No Maybe
    * Take the ships wheel	Please Select Yes No Maybe
    *  I just want to relax and chill out	Please Select Yes No Maybe
    * Do you consume alcohol	Please Select Yes No Maybe
    * Kayaking	Please Select Yes No Maybe
    * Jet Skiing	Please Select Yes No Maybe
    * Take flight on a Ultra Light	Please Select Yes No Maybe
    * Operating the dingy	Please Select Yes No Maybe
    * Island Tours	Please Select Yes No Maybe
    * Private secluded beaches	Please Select Yes No Maybe
    * Alternative Lifestyle	Please Select Yes No Maybe

     

18. Please provide the following Emergency contact information:

    Title
    * First Name
    * Last Name
    Organization
    * Street Address
    Address (cont.)
    * City
    * State/Province
    * Zip/Postal Code
    * Country
    Work Phone
    * Home Phone
    E-mail
    * Relationship

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