BATELEUR SAFARIS - SAFARI RESERVATION FORM Please complete in full so we can cater to your needs. Fax/Tel: International (011)2714-743-2329 / Local (014)743-2329 Mailing Address: P.O. Box 1619, Potgietersrus, 0600 South Africa PERSONAL Full Name:__________________________________________________ Date of Birth:__________ Marital Status:_________ Occupation:_________________________________________________ Home Address:_________________________________________ Home Phone:___________________ Work Address:_________________________________________ Work Phone:___________________ Fax:_______________________________________ Email:___________________________________ NEXT OF KIN (Notify in case of emergency) Name:_________________________________________________ Home Phone:___________________ Address:______________________________________________ Work Phone:___________________ SAFARI DATES & ITINERARY Arrival:_______________________ Time:_________________ Port:_________________________ Depart:________________________ Time:_________________ Port:_________________________ # of days:____ # in Party:____ Hunters:____ Observers:____ Children:____ Under12:____ Hotel Req:_____________________________ Air Charter Req:_____________________________ Special Arrangements:________________________________________________________________ Photo Safari Arrangements:_____ Days:_____ Interests:________________________________ HUNTING REQUIREMENTS Species (specify):___________________________________________________________________ Firearms: Make:_______________ Calibre (min .30):_____ Serial No.:___________________           Make:_______________ Calibre (min .30):_____ Serial No.:___________________ Cites Permits Required:______________________________________________________________ FOOD AND BEVERAGE Wine (W/R):____ Beer:___________ Spirits:___________ Minerals and Juices:____________ Food Preference:_____________________________________________________________________ Dislikes and Allergies:______________________________________________________________ HEALTH Allergies:_________________________________________ Bees:_________ Blood Type:_______ Antibiotics:_____________________ Other:_____________________________________________ INDEMNITY: I, THE UNDERSIGNED DO HEREBY INDEMNIFY THE MEMBERS AND STAFF OF BATELEUR SAFARIS AND ITS ASSOCIATES OR PERSONS ACTING FOR OR ON ITS BEHALF AGAINST ANY LOSS OR DAMAGE CAUSED DIRECTLY OR INDIRECTLY BY SICKNESS, INJURY, DEATH OR LOSS, OR DAMAGE TO PROPERTY WHETHER OCCURRED BY NEGLIGENCE OR NOT, OR ANY EXPENSES ARISING THEREFROM, WHICH I MAY SUFFER WHILE WITH BATELEUR SAFARIS. Deposit Paid:_____________ Date:_________________ By:________________________________ Signed by Client:________________________________________________ Date:______________ Signed by Outfitter:_____________________________________________ Date:______________ Comments:____________________________________________________________________________