Your Name - exactly as it appears on your passport: Nickname - name by which you wish to be addressed: Mother's maiden name:
Place of birth: Date of birth:
Your Email Your mailing address:
Your landline: Your cellphone:
Citizenship and Passport number: Passport expiration:
Date of delegation departure: Date of delegation return: Preferred accommodations (if available) Single/Double/Either:
Emergency contact: Special needs:
Have you travelled to Cuba before? Yes/No Date of most recent visit to Cuba:
Proficiency in Spanish? None/Poor/Good/Advanced Bio that includes your work, play, and interest in Cuba:
Upload scan (or photo) of the signature and photo page of your passport in high resolution and color (may be in jpg, jpeg, png, gif, or pdf format - Max size 3MB): Upload the scan of the signed Release from Liability form (may be in jpg, jpeg, png, gif, or pdf format - Max size 4MB):
Have you uploaded the scan of your passport? Yes/No Have you uploaded the scan of your Release from Liability form? Yes/No Have you sent the deposit? Yes/No
Application date:
Alternatively, if you cannot make this work, then please snail mail hard-copy of the above mentioned documents together with your $500 deposit to: The Friendship Association, 7265 A.1.A. South, Apt. D-1 A1A South, Apt D1, Saint Augustine, FL 32080.
