Please print the following form, fill in as much information as possible, and mail or fax to: PIED PIPER TRAVEL 330 West 42nd. Street - Suite 1804 New York, NY 10036 Fax: (212) 239-2275

Please put me on the roommate share list for PIED PIPER's gay group cruises:

Full Name __________________________________________________________

Address ___________________________________________________________

City _________________________ State _______ Zip Code _____________

Telephone (Home) ________________________ (Work)__________________

Email: __________________________________________________________

Best time and place to reach me: ________________________________________

Can we leave a message? ___Yes____No.

Please tell us how you heard of us: (Which magazine/publication?, Internet link-Which webpage?, friend/previous passenger, etc.) ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Do you currently have a favorite travel agent? (PIED PIPER pays commissions to certified travel agents for its gay group cruises!)

Travel Agent's name _____________________ Telephone #_________________

Travel Agency name _____________________ Agency Fax # ________________

Travel Agency address ________________________________________________

Please list the particular PIED PIPER gay group cruise you would like a roommate share for:

_______________________________________________________

Which categories would you like to be listed for? _____________________

Would you like a smoker or non-smoker as a roommate? _____________________

Thank you for your interest in our cruises! We will call you as soon as we find a roommate for you to make sure you're still interested. Hope to see you onboard!

PLEASE NOTE THAT ALL PAYMENTS MADE FOR SHARE RESERVATIONS ARE NON-REFUNDABLE UNLESS A SHARE REPLACEMENT CAN BE FOUND

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