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Full Name *

Street Address *

City, State, & Zip Code *

Age, and Date of Birth *

Home Phone ( including area code ) *

Cell Phone Number *

Are you a Smoker (Yes) or (No) *

Do you chew Tobacco (Yes) or (No) *

Do you have any Heath Problems ( Please Explain ) *

Do you have any Cronic Illness ( Please Explain ) *

List Doctor Prescribed Medication you take. *

Are you a U.S. Citizen (Yes) or (No) *

Do you have a Valid U.S. Passport (Yes) or (No) *

When would you like to travel to the Philippines? ( Give Dates ) *

How long would you like to stay in the Philippines? One Week, Two Weeks, Three Weeks, or Longer? *

What goals do you have for this trip? Retirement, Romance, Island Hopping, or ALL? *

Do you have any Special Requests for this Trip? *

Have you traveled outside the U.S. before? Which Countries have you Visited and When? *

Do you have any Questions about my - Personal Assistant Offer?

Please list the amout of your Monthly Retirement (NOT Required but is Helpful)

Did you find our Website Helpfull and Informative?

Do you have any Suggestions that you would like to share with me?

Do you have Retired "Single" Friends that would be Interested in this Service?

Do you need help with obtaining a Passport?

What is the best time to contact You by Phone? ( Morning? Afternoon? Evening? or Specify a Time during the Day )


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