< Deadline : April 27th, 2011 >☆YOU MUST TYPE OR PRINT CLEARLY!!☆
1Last Name

Name
(Exactly as it appearsin passport)
Month2First Name

DayYearMiddle Name

3. Age4. Gender

Date of BirthStreet:5Address

City:
State:

6

Telephone

7Fax

8E-mail address

9

Occupation / Grade

Zip:
Cell:

@Discount :□ Child Discount* 11 years and under: $250 discount.

10Hobbies / Interests

11Allergies

12Pets13

Are you a smoker?

14Like・□ Student Discount□ Infant under 2 years old* Student between 12 & 25 years.: $200 discount.

Dislike*Infant: $300 fo all costs

What kind of pets do you dislike?

Do you mind if your host family smokes?
Foods you can't eat / won't eat.

15Special Needs /Note to Host Family
16

Family Members (This information helps us match you with a similar family in Japan)
Name

Relationship

Occupation

Age

17

Preferred Hotel Companion?
18 (All rooms are based on double occupancy. Single participants will be paired up withName:another participant to share a room)

19 Would you prefer a single room in the hotels? (at extra cost)
Basically, one participant stays at one host's house. However, because of special
20 reason (wife and husband, parent and child, etc.), if you want to homestay withsomeone else, please write his/her name. (Due to the house space, this request may not
be guaranteed.)

YES
NAME・

NO
RelationshipLOCAL SESSION CHOICE
Please insert the number and name of your 1st and 2nd choices.
(Please see the brochure for Local Session details. Your preference will be considered, but not guranteed.)21

1. Nahari 2. Aki 3. Kami 4. Konan 5. Nankoku 6. Kochi A 7. Kochi B 8. Kochi C
9. Ochi 10. Sakawa 11. Ohnomi / Nakatosa 12. Kure / Nakatosa 13. Tosashimizu 14. Kochi D
1st choice: (̲̲̲̲̲̲)̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

2nd choice (̲̲̲̲̲)̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲OPTIONAL SAWACHI DINING on July 3rd22

Please chedk the right box, if you want to join the Sawachi Dining Experience. (at extra cost of $55)

POST SUMMIT OPTIONAL PROGRAM
Please insert the alphabet and name of your 1st and 2nd choices. (Please see the brochure for the details.)

A. Tokyo Free
B. Kyoto Homestay & Tokyo
C. Dogo Spa, Hiroshima & Tokyo
D. Dogo Spa, Hiroshima, Kyoto & Tokyo
E. Kochi Extension (nights)

23

1st : (̲̲̲̲̲)̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

2nd : (̲̲̲̲̲)̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

If you prefer a single room at the hotel during the optional program,24 please check the right box. (at extra cost of $40 / night)

25

If you want to extend your stay inTokyo, how many nights? ($100/night)nightsTRAVEL INFORMATION
26 Passport Number:

27

28 Passport Expiration Date (DD/MM/YYYY) :/Nationality:/

29 Person(s) traveling with you:
30 Desired Departure Airport (City & State):
31 Desired Departure Date / Desired Return Date:
32 Special Request (meals, desired seating etc.)
33 Do you require travel insurance?

Yes / No (Travel insurance is your own responsibility)

KIMONO(YUKATA) SIZE
The following information is needed by the hotels to help them choose appropriate
yukata (cotton kimono) for you.
Please choose from list right (e.g. medium). If your size is not on the list, please write
it in inches.
34

YUKATA Size: ( Adult / Child )̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

Please send this application form
with your passport copy and deposit to:
KIE/ Kintetsu International Travel Consultants Company (TCC)
Address : 1290 Avenue of the Americas, Suite 900 New York NY 10104

Telephone : 212-259-9640

E-mail : Manjiro@kintetsu.com

Passport Copy: Please make a photocopy of the page ofyour name, passport number, expiration day.
Deposit: A check of $300 made out to KIE must be sent at
the time of application. The deposit will count towards
the total cost.
THE DEADLINE IS APRIL 27TH, 2011

■YUKATA Size (for Adult)
Size

HeightSmall

4.7 - 5.0 feetMedium

5.0 - 5.4 feetLarge

5.4 - 5.7 feet

X Large

5.7 feet --■YUKATA Size (for child)
Size
HeightSmall
2.5 - 3.7 feetMedium
3.7 - 4.2 feetLarge
4.2 - 4.4 feet
[ CONTACT ]REGARDING TRAVEL(special flight arrangements or considerations)
Please contact Mr. Mitsumura, Ms. Matsumura
or Mr. Yamakoshi of KIE (see info on the left).
Office hour : 9:00 am - 5:30 pm EST, Mon.- Fri.
REGARDING THE SUMMIT:
Mr. Ted Uchida (Summit Volunteer Coordinator)
Telephone: 408-828-7813 ( Gilroy, California)
E-mail : s.teduchida@gmail.com*The program organizers reserve the right to approve, deny or cancel any application at their discretion and to alter the program and activities at any time.