Name _______________________________________         O M        O F

Address __________________________________________________________________________________________________

Phone __________________

E Mail_______________________________________

Name as you wish it to appear on badge _________________________

Prefered Departure City _______________________

Smoking? yes O no O

Special Diet? _________________________________

Total enclosed: $ __________ Balance due: $ ____________

Please note: If you are registering as a single, you will be assigned a double room with another single of the same sex. Single supplement is also available if you prefer private accommodations for an additional charge of $375

If you prefer a roommate Please give name. _________________________________________________

Do you want your name and telephone number appear on tour roster? Yes O No O

Make check or money order in U.S. dollars payable to: Middle Eastern Music and Dance,

and Mail To: Middle Eastern Music and Dance, 3244 Overland Ave., No. 1, Los Angeles, CA 90034.

PHOTO RELEASE STATEMENT: By registering to go on this tour, each attendee grants Middle Eastern Music and Dance productions, its employees, agents and assigns; the use of attendee's likeness, voice, sound effects and/or musical performance in photographs, motion pictures, videotapes, and recording media. Each attendee also grants in perpetuity the right to reproduce and/or redistribute in any manner whatsoever the attendees likeness, voice, sound effects and/or musical performance.