Customized Holidays Submission Form

Section 1. Personal Information

Title

First Name

Last Name

Postal address

(civic number, street, city, state or province)

Country/Nationality

Phone number(with area code)

Email address

( e.g. : name@domain.com )

Section 2. Guest Detail

Number of Participants

Number of Adult

Adult Ages

( ex : 13, 20, 33, 40,...)

Number of children (Under 12 Years Old)

Children ages

( ex : 12, 6,...)

Entry Date

Entry City

Duration of travel

day(s)

Exit City

Choice of Destinations

Bali

Yes No

Java ( Borobudur/Ijen) :

Yes No

Toraja/Sulawesi

Yes No

Gili's island/Lombok

Yes No

Sumatera/Orang Utan

Yes No

Volcano Trekking

Yes No

Section 3. Category of Tours

What kind of category holiday would you like?

Type of travel project

Do you want your trip to be :

Highly Moderate Relaxing

With driver / guide and car at arrangement.

Without car nor driver / guide (independent arrangement).

Guide Speaking

Section 4. Hotel Choice

Number of double rooms

Number of single rooms

What kind of accommodation would you like to stay in?

	Small	Medium	Hight
Standard
Superior
Deluxe
Bungalow/Cottage
International Class Hotels

Section 5. Activity Choice

Indicate us your activities preferences in which you wish to participate

Cultural activities	Small priority	Medium priority	High priority
• Traditional festivities
• Traditional dance and music 'shows'
• Museum and art galleries
• Handy craft workshops/Cottage
• Royal palaces
• Traditional markets

Nature and adventure	Small priority	Medium priority	High priority
• Volcano climbing
• Countryside walks
• Trekking
• Cycling
• Rafting
• Fishing trips
• Natural parks
• Mountain and rice fields
• Ecotourism

Body and soul	Small priority	Medium priority	High priority
• Traditional massage
• Reflexology and shiatsu
• Body treatments
• Hot springs

Leisure	Small priority	Medium priority	High priority
• Shopping
• Nightlife
• Beach and sea
• Dining

Section 6. Additional Information

Have you been in Indonesia before?

Yes No

The region that you have been visited in Indonesia

If you wish to include further comment

You knew our site by the intermediary:

Of a Search engine
Of the link of another site, in that case which: or other one
Of an appearance
Of a friend which advised it to you
Other, clarify:

I have read the terms and conditions and I accept them. (This box must be checked)

Enter security code to continue
To prevent spamming, please enter in the security code in the box below