Blacks Over 40 at Sea 2012

Cruise Host Enrollment

Cruise Host_________________________________________

Address___________________________________________

Day Phone____________________________

Evening Phone_________________________

Email________________________________

Group Name___________________________

I have read the Group Policies and Procedures and agree to comply to them as stated.

______________________________________________________

Signature                         Date

Please sign and return this enrollment form to:

Blacks Over 40

P. O. Box 18865

Philadelphia, PA 19119

Fax:  775-213-3121

Email:  Cruise@BlacksOver40.org

Upon receipt of this enrollment form, your reservation and deposit, you will be provided with a group number and will receive credit for all fully paid passengers under the group number.