Mir Center

Thank you for your interest in our pilgrimage to MEDJUGORJE on 12/21/2010. Please file out the form below to the best of your ability.

PILGRIM(s) INFORMATION (name MUST match your passport)

PILGRIM 1
First and middle name:
Last name:
Date of birth:
Nationality:
Passport number:
Expiration date:
PILGRIM 2
First and middle name:
Last name:
Date of birth:
Nationality:
Passport number:
Expiration date:
PILGRIM 3
First and middle name:
Last name:
Date of birth:
Nationality:
Passport number:
Expiration date:

Address:
Address:
City:
State:
Zip Code:
Country:

Home Phone:
Work/Cell Phone:
Fax:
Email:

Promoters Name:
Departure City:
Accommodations:
Roommate Name:
Airplane Seat Request:
Other requests/comments :
Emergency Contact:	Name & Phone Number
Reservation made by :
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