Please fill in the following fields:
1. Personal Information
Agency Number
In case you came from one
First name
*
Last name
*
Company / Group / Mission Name
Address
*
City
*
Country
*
State
US Citizens Only
ZIP/Post Code
*
Phone No
**
Mobile No
**
Fax
Email
*
2. Billing Information
Same as Personal Information
First name
*
Last name
*
Company / Group / Mission Name
Address
*
City
*
Country
*
State
US Citizens Only
ZIP/Post Code
*
Phone No
*
3. Delivery Options
Same as Personal Information
Number of Phones Requested
*
1
1
2
3
4
5
6
7
8
9
10
Rental Date
*
From:
To:
First name
Last name
*
Deliver to:
Hotel
Other
Flight No:
Airline:
Arrival Date:
Hotel Name:
Address
City
*
Phone No
Company / Group / Mission Name:
*
4. Credit Card Information
I would like to give my credit card details by phone
Card Type
*
--- Choose One ---
Visa
Isracard
Mastercard
Diners
American Express
Card Number
*
numeric digits only
Expiration Date
*
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
/
1
2
3
4
5
6
7
8
9
10
11
12
Card holder Name
*
Card ID Number
(3 digits behind the card)
Passport ID
Mandatory Fields
5. How did you hear about us ?
--- Choose one ---
UJA Federation
UIA Federations Canada
A friend/colleague referred me to you
Website
Direct Mail
Advertisement
Search Engine
Organized Group
Other
1.
Request Information
2. Verify Order
Tel Aviv:
POB 36429, 61363 Tel Aviv
Mobile. +972.52.3327777 (George)
Phone. +972.3.6445913
Fax. +972.3.6499889
Jerusalem:
1 Hamarpe st., Har Hachozvim, Jerusalem
Mobile. +972.50.5286686 (Shimon)
Phone. +972.2.5711555
Fax. +972.2.5711777
