P. O. Box 4554 ~ Potgietersrus ~ 0600 ~ South Africa
Tel/Fax : (27) 15 453 0652 Mobile : (27) 82 968 1778
e-mail: safari.afrika@safariafrika.net
       This original form must be completed and mailed or faxed to the below address
                          as soon as possible in order for us to prepare for your Safari   


Personal Details              

Surname: ______________________________________ First name(s): ________________________________

Address(Home): ____________________________________________________________________________

_________________________________________________________________________________________

Tel No: ________________________________________ Fax No: ____________________________________

E-mail address: _______________________________________         

Address(Work): ____________________________________________________________________________

_________________________________________________________________________________________

Tel No: ________________________________________ Fax No: ____________________________________

E-mail address: _______________________________________         

Contact Numbers
Person to notify in case of an emergency                

Name: _________________________________________Tel No: ____________________________________

Address: _________________________________________________________________________________

_________________________________________________________________________________________

E-mail address: _______________________________________       

Safari Dates & Information                

Number of days: _____________________               

Dates from: ______________________________________ to: _______________________________________

Number in your party: _________________ Observers: __________________ Children:_________________  

Animal species you wish to hunt :        ____________________________  ____________________________

____________________________  ____________________________  ____________________________

____________________________  ____________________________  ____________________________


CITES and other Licenses : ____________________________________________________

Will you bring your own firearms ? Yes  ________________   No  ________________


Please give us your Itinerary

Arrival Date: _____________________________Airline & Flight Number: _______________________________

Arrival Time: ______________________________

Departure Date: __________________________ Airline & Flight  Number: ______________________________

Departure Time: ___________________________

If you would like to do sightseeing before of after your hunt, please specify your interests :

_________________________________________________________________________________________

_________________________________________________________________________________________

So that our kitchen & household staff can make your stay enjoyable, please tell us your :

Food preferences: __________________________________________________________________________

Food allergies: _____________________________________________________________________________

Food dislikes: _____________________________________________________________________________

Are you a diabetic ? Yes:__________    No: __________

Do you require a low-salt, diabetic or any other special diet: Yes:__________    No: __________

If so, please specify: _________________________________________________________________________

Beverages preferences - Spirits: ________________________________________________________________

Wine: ________________________________________ Beer: _______________________________________

Juices & soft drinks: _________________________________________________________________________

Please tell us about your health

Allergies to insects and / or antibiotics etc.: ________________________________________________________

Special medical conditions: ___________________________________________________________________

Special medications you may be taking: __________________________________________________________

________________________________________________________________________________________

Blood type: _______________________________

Note : please attach a copy of the picture page of your passport