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Donor

Patient

Patient Companion

Your Name

Email Address

CellPhone

D.O.B

Country

Street Address

City

State

Zip Code

Rabbinical reference

Reason of Medical Travel Necessary

Facility Name

Referred To Medical Facility By

Facility Country

Facility Address

Facility City

Facility State

Facility Zip Code

Hebrew Name

Card Holder

Card Number

Expiration Date

CVV

I agree to the following terms and conditions.

We can only process a booking if the appointment is confirmed.

For any Non-emergency reason, the ticket is not used you will be responsible to pay the cost (based on the mileage value) charge will apply on credit card on file.

Processing fee is $25 per ticket.

Please choose one of the following options:-

I am ready to pay for the tickets for the above trips and would like Miles for Lifeto help me get the best price available Terms & Conditions.

I need financial help to cover the airline tickets for the above trips and no one inthe family got miles to contribute.

I have miles to contribute for my tickets and would like to use the Miles for Lifeservice of booking the tickets.

Printed Name

Signatures

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