Robertson Punta Cana Trip Registration

Please complete the following information to register for the Robertson Heating Supply Punta Cana Trip. If you need assistance, please contact Debbie Goshorn, Event Coordinator, at (330) 821-9180 ext. 131 or debbieg@rhsonline.net. The deadline to submit this form is Friday, January 6, 2012.

I. Primary Attendee

Robertson Account Information

Robertson Account Number (6 digits): *

Robertson Sales Rep: *

Personal Information

First Name (as it appears on your passport): *

Middle Name (as it appears on your passport): *

Last Name (as it appears on your passport): *

Name Badge First Name: *

Name Badge Last Name: *

Gender (per U.S. Dept. of Homeland Security): *

Date of Birth (per U.S. Dept. of Homeland Security): *

Home Phone area code 1st; no dashes or spaces):

Cell Phone area code 1st; no dashes or spaces): *

E-mail Address: *

Business Information

Business Name: *

Business Phone area code 1st; no dashes or spaces): *

Business Address 1: *

Business Address 2:

Business Address 3:

Business City: *

Business Country: *

Business State/Province: *

Business ZIP/Postal Code (5 or 9 digits; no dashes or spaces): *

Passport Information

Passport Number: *

Passport Country: *

Passport Expiration Date: *

Emergency Contact Information

Emergency Contact Name: *

Emergency Contact Phone (area code 1st; no dashes or spaces): *

Miscellaneous Information

Special Diet or Health:

Trip Preference Information

Preferred Hotel Check-In Date: *

Preferred Hotel Check-Out Date: *

Bed Type Preference: *

Special Trip Request:

Air Transportation

Departure Airport-Option #1: *

Departure Airport-Option #2: *

Departure Airport-Other

II. Guest Attendee

Personal Information

First Name (as it appears on your passport): *

Middle Name (as it appears on your passport): *

Last Name (as it appears on your passport): *

Name Badge First Name: *

Name Badge Last Name: *

Gender (per U.S. Dept. of Homeland Security): *

Date of Birth (per U.S. Dept. of Homeland Security): *

Passport Information

Passport Number: *

Passport Country: *

Passport Expiration Date: *

Miscellaneous Information

Special Diet or Health:

Trip Preference Information

Preferred Hotel Check-In Date: *

Preferred Hotel Check-Out Date: *

Bed Type Preference: *

Special Trip Request:

Air Transportation

Departure Airport-Option #1: *

Departure Airport-Option #2: *

Departure Airport-Other

III. Robertson Sponsored Activities

The activities on Thursday, March 8th and Friday, March 9th are optional activities. If you choose not to participate in activities on these days, please select 'Day at Leisure'. Please note, for activities requiring a fee, YOU WILL BE REQUIRED TO PROVIDE PAYMENT UPON RECEIPT OF THIS FORM.

The activities on Saturday, March 10th are compliments of Robertson Heating Supply and are free of charge. You may attend one or both activities. If you choose not to participate in these activities, please select 'Day at Leisure'.

Thursday, March 8 Floating Ocean Spa ($75/person): Prime Guest
Golf Outing (no charge): Prime Guest
Day at Leisure (no charge): Prime Guest

Friday, March 9 Dolphin Explorer Program ($153/person): Prime Guest
Snuba, Speed Boat, Snorkel ($165/single; $105/double): Prime Guest
Day at Leisure (no charge): Prime Guest

Saturday, March 10 Robertson Texas Hold 'Em Tournament (no charge): Prime Guest
Robertson Beach Olympics (no charge): Prime Guest
Day at Leisure (no charge): Prime Guest

Please note that Robertson Heating Supply and affiliated companies shall not be held liable for any injury, damage, loss, expense, accident, delay, inconvenience, or irregularity arising out of or relating to said participation in activities.