First Name
Last Name
Title
No. of Adults
Children
Hotel To Stay
Street Address
Address (cont.)
City
Country
Cell Phone
FAX
E-mail
Arrival Date
Departure Date
Arrival Time
You are Booking	1 Day Shimba Hills Extension to Mwaluganje Select one Yes No

             Arrival Airport      Please Select One Jomo Kenyatta Aiport- Nairobi Moil Airport- Mombasa   Transfer Required Please Select one YES NO

            Please select the  mode of transport of your choice from the drop down lists below.

            Jeep/Minibus? Please Select One Jeep Safari Minibus

   Please Enter the Date of your Safari  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 Day January February March April May June July August September October November December Month Year 2009 2010 2011

             Additional Requests (Please Provide Full Names of the Party)