UltraMind Form

Please print this form, fill it out completely, and mail it along with the deposit to:

International Group Cruises, Inc.

Attn: Victor Kovens

6717 Chippewa Drive

Baltimore, MD 21209

Name:

Address:

City/State/Zip:

Daytime Telephone #

Fax #:

E-Mail Address:

Type of Cabin: (mark with an X)

Inside

Ocean View

Balcony

Single

Rooming with:

Type of Payment:

Check enclosed

Charge (MC, Visa, Discover, AMEX, etc)

Credit card #: Exp. Date:

Signature:

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