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Name :
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Email :
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Phone :
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Date Of Birth (dd/mm/yyyy) :
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Passport Number :
Address :
Post Code or Zip Code :
Country :
Next of Kin :
Relation :
Email :
Phone :
Placement :
please select...
Protect - Gibbon Rehabilitation
Protect - Turtle Conversation
Protect - Dog Rescue
Protect - Work with Elephants
Care - Student Nursing
Care - General Medical
Care - Child Therapy
Care - Child Watch
Care - Children Home
Develop - School Development
Develop - Home Building
Develop - Children's Home
Develop - Community
Develop - Summer Special
Teach - Summer Break
Teach - Teaching English
Length of stay : (if known)
2 weeks
4 weeks
6 weeks
8 weeks
10 weeks
12 weeks
not sure
Arrival date : (if known)
??
January 08
February 08
March 08
April 08
May 08
June 08
July 08
August 08
September 08
October 08
November 08
December 08
2009
Comments :
Group :
please select...
Yes
No
If yes, Give Name :
Would you like to combine this Venture?
please select...
Yes
No
If yes, which Ventures would you like to combine?
(Please type their names in the box)
Agree to terms and conditions
I confirm that the information provided is correct. I have read and understood all the information and agree to all the terms and conditions on Starfish Venture's website with regard to application procedure, acceptance of risk, safety policy, foriegn office advice, security and any inconveniences that may arise in the developing world outside of the control of Starfish Ventures Ltd.
Agree
Security Code :
Type Security Code(UPPERCASE) :
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