_{Easy Life
Fax Inquiry / Booking}

to: Easy Life Tours & Rentals Australia
att. Pia
Phone: 0061 7 5494 7961
Fax: 0061 7 5406 0958
Email: pia@easylife.net.au

from: phone:

fax/email:

Where did you get our address from?

Please send an offer: [ ] a contract: [ ]

vehicle:

EMU2 or EMU3 (2 and 3-berth camper), EMU4 or EMU6 (motorhomes), B2B (campervan), BUSHKANGAROO (4WD-camper),

Period from: to:

Pick up: Drop off:

Cover options [ ] CDW [ ] CC

Number of adults: children: age of children:

Special needs:

Date of arrival: flight no: time: airline:

Date of departure: flight no: time: airline:

Surname: first name:

Address:

Date of birth: attainable till:

Phone No: Fax No or e-mail:

Passengers name & date of birth:

deposit payable by: bankaccount [ ] creditcard [ ]
the balance: bankaccount [ ] creditcard [ ] cash [ ] A$ traveller cheques [ ]

Mastercard |_| Visa |_| Name on card:

Card no. |_|_|_|_| |_|_|_|_| |_|_|_|_| |_|_|_|_|
exp. date: |_|_| / |_|_|
ver. code: |_|_||_| (last 3 digits on signature strip on back of card)