Print out this form, complete it and mail it together with China Tour Features & Condition Form, $200 deposit, and one passport-sized picture, to: East West Exchange, Inc. 4 Commodore Dr. #442, Emeryville, CA 94608

APPLICATION FORM

PHOTO

Name: _________________________________________________

Address: ________________________________________________

City: ____________________ State: ___________ Zip: __________

Home Phone: (____)_______________ Sex: ______ Age: ________

Employer: _______________________________________________

Address: ________________________________________________
City: ______________________ State: _____ Zip: ___________
Work Phone: (____)___________

EMERGENCY CONTACT: Name: _________________________________

Address: _______________________ City: ___________ State: _____ Zip: _________

Phone: (___)___________ Relationship: _____________________


PROGRAM YOU WANT TO JOIN: Acupuncture ____ Massage ____ Qigong ____

Need a single supplement ($500 additional fee) _____ Smoking____ Nonsmoking______

Airport you would like to depart _________________________
If the 1st choice is not available, the 2nd choice of airport ______________________

SPECIAL NEEDS OR MEDICAL PROBLEMS:

________________________________________________________________________

________________________________________________________________________


SIGNATURE _______________________________ DATE ______________________