APPLICATION

VIET NAM JOURNEY

September 13 -24,  2012

Name _______________________________________________________________

             (Last)                               (First)                             (Middle)

Address _____________________________________________________________

City       __________________ State ____________  Zipcode __________________

Mailing Address

   C/O Organization (If any) _____________________________________________

   Address ___________________________________________________________

   City ____________________  State _______________   Zipcode _____________

**Passport Delivery Address**

  C/O Organization (If any) ____________________________________________

  Address  ___________________________________________________________

  City __________________  State __________________ Zipcode _____________

Current Occupation/Profession: _________________________________________

Home # ________________  Work # _______________  Cell # ________________

Fax # _________________  Pager # _______________  Email __________________

DOB ________________  Citizenship ____________________________________

Passport # _________________________  Expiration Date ____________________

If you do not have a passport can you obtain one by August 1, 2012? ____________

1.       Are you a Vietnam Veteran?  Yes ____  No  ____

                   If so:

A)What time period did you serve in Vietnam?  From ___________ to _________

B)What was your branch of service and rank? _____________________________

C)What were your duties? _____________________________________________

D)Where did you serve?  ______________________________________________

E)Have you returned to Vietnam since your military service? Yes _____  No _____

If so:

       When? ____________ Purpose of your trip: _________________________

If not:

A)Are you related to a Vietnam veteran?  Yes _____  No _____

                         If so:

        What relationship? _____________________________________________

                                   Is that veteran deceased? Yes _____  No _____

B)Have you ever traveled to Vietnam? Yes _____  No _____

If so:

       When? ______________ Purpose of your trip? __________________

2.  Is this your first time to apply for The Vietnam Journey?  Yes ____  No ____

3.  Have you ever applied or returned to Vietnam with Rupert Harrell Ministries?  Yes _____ No _____

4.  Why do you want to participate in The Vietnam Journey Tour?

     ______________________________________________________________

5.  Are you a Christian?  Yes _____  No _____

           If so:

                    When were you born again? ________________________________

                    Pastor’s name and address:

                   Name ____________________ Church Name _____________________

                   Church Address _____________________________________________

                   City _________________ State _____________  Zipcode ___________

                   Office Phone ___________________  Fax ________________________

                   Home Phone __________________ Email ________________________

         If not:

             Will you agree to attend all morning chapels and other Vietnam Journey

               activities?  Yes ____  No  _____

             Will you abide by our rules of conduct which includes a curfew and no alcohol?

              Yes ____  No ____

       We need a confidential letter of reference.  Who will be sending that letter?

        Name ______________________  Relationship _________________________

        Address _________________________________________________________

        City _________________  State ____________  Zipcode  _________________

        Home Phone ________________ Email _______________________________

        Note: THIS LETTER MUST BE RECEIVED BY RUPERT HARRELL MINISTRIES/

                  THE VIETNAM JOURNEY IN A SEPARATE ENVELOPE PRIOR TO

                  ACCEPTANCE OF APPLICATION.  See mailing address at bottom of form

6.  Do you have a physical or emotional (PTSD) disabilities that are related to your service in Vietnam?  Yes ____  No  _____

          If so: What are your restrictions? __________________________________

7.  Do you have any disabilities that would require special assistance in travel?

    Yes ____ No ____ 

    If so: Please let us know what type of assistance you would need.

   _________________________________________________________________

8.  Please list any medications that you are taking. ___________________________

    _________________________________________________________________

9.  Is your health insurance adequate for overseas travel?

              Name of company _____________________________________________

              Please provide a copy of your insurance card.

10. What is your blood type? ____________________________________________

11. If your application is approved, full payment to Rupert Harrell Misitries is due by

     August 1, 2012  Can you do this? ____________

12. Hotel roommate requested (if possible) ________________________________

       The application will be kept in our office in strict confidence, with $500.00 deposit.

          Return to:  The Vietnam Journey  PO Box 688  Springtown, TX  76082

                                                     

                                                      Harrellcwby1948@aol.com