Emperador Hotel, Buenos Aires, Argentina

January 7 -15, 2010

Note:  Mac Users may encounter issues with this form if so please print the below provided pdf and send that in with your payment.

I am/We are unable  to attend.  Thank you for the opportunity.

I / We plan to vacation in Buenos Aires with Hirsch Pipe & Supply

I / We request 1 2 3 4 trip(s), based on eligibility and availability.

  Choose # of Trips 1 Trip at $250 2 Trips at $500 3 Trips at $750 4 Trips at $1000 Please hold   1 2 3 4 reservation(s).

Please remit deposit amount of $ Choose # of Trips 1 Trip: $250 Deposit 2 Trips: $500 Deposit 3 Trips: $750 Deposit 4 Trips: $1000 Deposit to 15025 Oxnard Street, Suite 100, Van Nuys, CA 91411, Attn: Marketing Department
 

Room preference: Smoking Non Smoking (based on availability)

Accommodations: Single Bed Double Beds

Dietary Request(s):

For special occasions or handicap request, please contact the Marketing Department at (818) 756-0900 or email mktg@hirsch.com.

Account #   Name

Company 

Home: Business:

Street Address: City:  State: Zip:

Home Telephone Number:    Cell Phone: 

Fax:   Email:

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Passport #:   Expiration Date:

If you are not a U.S. Citizen, please indicate the country of citizenship here: 

Date of Birth: Nickname for Name Badge:  Gender: Male Female

Upload an image of your passport here.  

______________________________________________________________________________

First Name:   Last Name:   Middle:

Passport #:   Expiration Date:

If you are not a U.S. Citizen, please indicate the country of citizenship here: 

Date of Birth: Nickname for Name Badge:  Gender: Male Female

Upload an image of your passport here.

______________________________________________________________________________

First Name:   Last Name:   Middle:

Passport #:   Expiration Date:

If you are not a U.S. Citizen, please indicate the country of citizenship here: 

Date of Birth: Nickname for Name Badge:  Gender: Male Female

Upload an image of your passport here.

______________________________________________________________________________

First Name:   Last Name:   Middle:

Passport #:   Expiration Date:

If you are not a U.S. Citizen, please indicate the country of citizenship here: 

Date of Birth: Nickname for Name Badge:  Gender: Male Female

Upload an image of your passport here.

______________________________________________________________________________

By hitting submit I certify I understand the terms discussed in the letter regarding this trip.

Thus, I also understand that this deposit is not refundable if for any reason I / we cannot

participate in the vacation after qualifying and committing.

Please type in code above to validate then hit submit.

When the password field pops-up copy and paste the following

into the top field: www.wts-trips.com\lisabrubaker

password: brubaker