Trip Application Full Name of Traveler(s)* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone Number* Email* Nationality*Please ensure your passport is valid 6 months after scheduled returnRoom ReservationRoom reservation*Single room (additional supplement)Shared, king sized bedShared, two twin bedsIf completing application separately, who will you be sharing a room with?Emergency ContactEmergency Contact Name* First Last Phone*Email* Additional InformationDo you have any dietary restrictions or allergies?*YesNoDescribe dietary restrictions and/or allergiesPlease describe any additional requests you haveHow did you hear about this trip?Medical Insurance and CancellationDo you wish to purchase medical insurance and cancellation protection plan?*YesNoMedical insurance and cancellation protection is an additional $595 USD for travelers under 60 years old. Our provider requires a medical questionnaire for travelers over 60 years of age in order to provide a quote. Please see policy for more details. Medical insurance and cancellation protection is nonrefundablePaymentAll prices are in US dollarsWestern and Central Bhutan with Lucie Edwards, 10 Days, Oct 23 – Nov 1 Price: $6,995.00 Quantity: Trekking and Eastern Bhutan Add-on, 16 Days, Oct 23 – Nov 7 Price: $9,995.00 Quantity: Trek and Eastern Bhutan add-on is an additional $3,000Travel Insurance Price: $595.00 Quantity: Includes medical insurance and cancellation protectionSingle supplement, Lucie Edwards Price: $995.00 Quantity: Total $0.00 Payment*Credit cardPay over the phoneChequeA deposit of $1,750 USD is required to reserve your space. Final balance is due 4 months prior to departure. CAPTCHAPlease make cheque payable to: The Bhutan Canada Foundation, 160 Avenue Road, Toronto, ON M5R 2H8; please note US Funds on the cheque We will contact you shortly to complete the payment.