QIBLATAYN INTERNATIONAL TRAVELS & TOURS

INTENDED PILGRIM APPLICATION FORM

RC: 1635464

PERSONAL INFORMATION

Intended Pilgrim's Name (SURNAME FIRST)

Date of Birth

Gender

Current Location

Address

Phone Number

Email Address

Qualification

Occupation

Nationality

Marital Status

Are you a retiree?

Yes

NEXT OF KIN INFORMATION

Name

Address

Relationship

Phone Number

Email Address

FOR FEMALE PILGRIMS ONLY

Name of Accompanying Male

Relationship to Pilgrim

Form Serial Number

Passport Number

Date Issued

Expiry Date

TRAVEL DOCUMENT INFORMATION

Do you have a valid international passport?

Yes

Passport Number

Issued Date

Place Issued

Expiry Date

HEALTH INFORMATION

Do you suffer from any chronic illness? (e.g. Hypertension, Diabetes, Arthritis, Asthma, etc)

Yes

If Yes, Give Details

Give Details of your regular drugs

REFERENCES

(At least one of whom must be an Imam)

Name

Address

Phone Number

PAYMENT DETAILS

Issuing Bank

Cheque No

Amount

PASSPORT CHECK

QIBLATAYN INTERNATIONAL TRAVELS & TOURS

INTENDED PILGRIM APPLICATION FORM

PERSONAL INFORMATION

NEXT OF KIN INFORMATION

FOR FEMALE PILGRIMS ONLY

TRAVEL DOCUMENT INFORMATION

HEALTH INFORMATION

REFERENCES

PAYMENT DETAILS

Let's get in touch

Phone Number

Email Address

Street Address

Website URL