Please complete electronically and email to:
Mr. Mrs. Miss. Dr. Enter names as they appear in your passport
Surname:Middles Name(s) if any First Name:
Address:
City:Email:
Province:Postal Code: Country:
Res. phone:Bus. phone: Cell:
Passport Number:Nationality:
Date of Issue:Place of Issue: Expiry Date:
Date of Birth:Place of Birth (City and Country):
Nationality: Previous Nationality:
Current marital status:SingleMarried Widowed Divorced
Current smoker? YesNoOccupation:
Emergency contact person and phone number:
Have you been for Hajj in the last five years? Yes No
Physical ability – Can you walk for 90mins. without needing a wheelchair? Yes No
Logistically, we are unable to accommodate those needing a wheelchair and children under age 15.
Married couples need a Government issued, English, legalnotarized marriage certificate.
Children (age 15+), will need alegal, notarized long birth certificatewith both parents’ names.
Approximate cost for Hajj will be $9250($4000 USD FUNDS, $4750 CDN).
Approximate dates are:Aug 06 toAug 26th2018
Please mail the following to 22 Mobray Place, Brampton ON, L6W 4M5:
1)A completed applicationform with your signature below
2)A photocopy of the page of your passport with your picture - even if it is expiring
3)A cheque payable to Hajj Assistance Services Inc.for $4750 CND (if you can pay the US portion, we will appreciate your help)
Limitation of Liability: The responsibility of Hajj Assistance Services Inc, 22 Mobray Place, Brampton ON, L6W4M5, hereinafter called HAS, or their agents, is limited. They act only as agents for the pilgrims in making arrangements for the airlines, hotels, buses, or any other services in connection with the performance of the Hajj and associated tours, and assumes no liability whatsoever for injury, damage, loss, accident, delay, cancellations or irregularity which may be occasioned either by reason of defect, through the acts or defaults of any company or person engaged in conveying the pilgrims or in carrying out the arrangements of the Hajj trip, or as a direct or indirect result of acts of God, and dangerous incidents in the air, sea, fire, and breakdown in machinery or equipment, acts of governments or other authorities de jure or de facto, wars, whether declared or not, hostilities, civil disturbances, strikes, riots, theft, pilferage, epidemics, quarantines, medical or customs regulations, or from any causes beyond control, or from any loss or damage resulting from improper passports, visas or other documents. HAS will accept no responsibility for loss or additional expenses due to delay or changes in schedule or other causes and HAS shall not be liable or responsible for anyinconvenience, loss, damage or injury arising in connection with such services. HAS will not be responsible for the failure to follow instructions, including but not limited to check-in and checkout times and baggage handling. In the event of delay, it is the responsibility of the airline to determine exactly what procedure will be followed. The policy chosen by that carrier shall be based on its procedure and shall not be the responsibility of HAS and itsaffiliates which will not be responsible for any person(s) missing any part of the Hajj, due to negligence or delay or absenteeism at any time during the Hajj trip and will not be responsible for any additional expenses for the participant to rejoin the trip. It is the responsibility of each traveler to purchase his/her own Trip Cancellation, Medical, Accident and Baggage Loss Insurance coverage offered by many Travel Insurance companies in North America. If visas are not obtainable for any pilgrim to visit any country planned for entry during the entire trip, due to any reason whatsoever, whether the efforts to secure visas were those of the pilgrim or HAS and its affiliates and agents, there will be no refund of any money paid. Airline tickets are generally issued as non-transferable and/or non-refundable. In the event of cancellation after ticket issuance, including failure of ticket holder to obtain visas, whether the efforts of the procedures to obtain them were those of the ticket holder or HAS and its affiliates and agents, no refund of ticket cost will be made unless the airline makes a refund. There is no guarantee that any airline will refund the cost of the airline ticket, in whole or in part, should such an event occur. The package price quoted is an estimate based on previous years costs, and is subject to change without notice, and all the conditions and charges mentioned will still be applicable. By signing below, the applicant attests that he/she has read and understood the limits of liability, and will not hold liable HAS and/or its affiliates and agents for any mishaps mentioned and not mentioned above, and will comply fully with the terms and conditions described herein.
Signature (name): Date: