Print this form and fill it out. Mail or fax to:
Patagonia Mountain Agency
P.O. Box 210516
Auke Bay, AK 99821
Call/Fax 907-789-1960
Web: www.alaska.net/~ptgmtnag/
email: ptgmtnag@alaska.net

BIODATA OF TEAM MEMBER


1. EXPEDITION NAME:
                                                 
2. Capacity in team (i.e. Member):

3. Family Name:                                       PHOTO

4. Given Name:

5. Date and Place of Birth:

6. Nationality:

7. Home Address:


8. Present Address:


9. Occupation:

10. Passport Number:

11. Previous Visits in Nepal:

12. Duration of Previous Visits:

13. Mountaineering Background:




Signature__________________________

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