VISA APPLICATION FORM

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1 Marazul C harters Inc. Tel (201) Outside NJ (toll-free) F ax (201) info@marazul.com VISA APPLICATION FORM Professionals Abroad Delegation to Cuba ASEE: AMERICAN SOCIETY FOR ENGINEERING EDUCATION FEBRUARY 19-24, 2018 Each person must complete all pages of this form. Please return with a clear copy of your passport information page Name as on passport last name, first name, middle initial, Mr./Mrs./Ms./Dr. Mother s Maiden Name Name for badge (Nickname) Company Name Title within company Date of birth Citizenship Passport number for international trips only Passport Place of Issue Passport Date of Issue Passport Expiration Date Place of Birth If a U.S. resident, non-citizen: Green Card Number Mailing address please provide a street address, not a P.O. Box City State Zip code Telephone day Telephone evening Cell Phone Do you speak Spanish? Have you traveled to Cuba before? If yes, when, and for how long? Interests in Cuba: List any special requests or events being celebrated: Professional Bio: Please provide a typed brief bio (up to 200 words) which highlights your professional accomplishments and how you feel you will add value to your delegation. You may use the following as writing prompts: 1. Please specify your most recent professional experience, area of expertise, and position. 2. Please list your affiliation with relevant professional societies, professional associations, and institutions. 3. Please list distinguishing professional accomplishments. 4. Please list three issues you would like to discuss during your professional exchange. Form continues on other side

2 HEALTH INFORMATION General statement of health (please note any medical conditions that we should be aware of while you are on this trip): Dietary restrictions, please be specific: Allergies to medication or food: Significant vision or hearing problems: Do you rely on any of the following: cane(s) or walking stick(s) walker wheelchair or scooter no aid required If you use any assistance to walk, how far can you walk unassisted? List any medications you take and the reason for taking them: ADDITIONAL INFORMATION Check whether you would prefer one bed or two beds, when applicable and available. List any special needs: Special events to be celebrated during the tour (e.g., anniversary): Occupation/Hobbies/Interests: Special reason for taking this tour: Companions on this tour and their relationship to you: TRIP CANCELLATION INSURANCE Trip cancellation insurance is strongly recommended and advised. See the Travel Insurance Services website for details concerning all benefits, as certain restrictions may apply. To purchase this insurance please call or visit their website at: Please advise whether you are purchasing optional trip cancellation insurance below. Yes (provide name of insurance company): No EMERGENCYCONTACTINFORMATION In case of an emergency, please notify: Name Relationship Telephone day Cell Pone Street address City State Zip Code

3 AGREEMENT, ASSUMPTION OF RISK, WAIVER AND RELEASE and your Delegate Communications Site include our statements of Responsibility and Terms and Conditions. As a condition to participate on the trip, each applicant must sign the following statement (parent or legal guardian must sign for each child): I have read the schedule of activities for this trip and recognize and accept the risks thereof. I have read and agree to the TERMS AND CONDITIONS and the RESPONSIBILITY statement for this trip and understand that they include a release of liability that will be binding upon me and my family, heirs, and legal representatives. I further agree to release and hold harmless the Academic Travel Abroad, Inc., and any of their offices, agents, licensees, or representatives from any and all liability for delays, injuries, or death; for the loss of or damage to his/her property; or of personal injury or property damage to others by him/her, however occurring, during any portion of, or in relation to the ASEE: American Society for Engineering Education Delegation to Cuba, February 19-24, Signature Date

MARAZUL RESPONSIBILITY AND LIABILITY AGREEMENT Professionals Abroad Delegation to Cuba ASEE: AMERICAN SOCIETY FOR ENGINEERING EDUCATION FEBRUARY 19-24, 2018 VISA INFORMATION*: Marazul Cha rters Inc.

com All travelers must have a valid passport which does not expire for 6 months past your return date, and a Cuban visa.

4 MARAZUL RESPONSIBILITY AND LIABILITY AGREEMENT Professionals Abroad Delegation to Cuba ASEE: AMERICAN SOCIETY FOR ENGINEERING EDUCATION FEBRUARY 19-24, 2018 VISA INFORMATION*: Marazul Cha rters Inc. Tel (201) Outside NJ (tollfree) Fax (201) marazul.com All travelers must have a valid passport which does not expire for 6 months past your return date, and a Cuban visa. You are responsible for having this proper documentation on your person to enter Cuba as well as to re-enter the United States. Also, if you are originating outside of the United States, you must have proper documentation to travel via the United States to Cuba. The Cuban Government retains the right to grant or deny visas. *Very important: persons born in Cuba, no matter what your current citizenship, will require additional documentation, and may not be able to obtain a Cuban visa. If a visa is not granted, you will not be able to travel to Cuba, and will receive a full refund of any monies received. Please contact ATA at for further information. RESPONSIBILITIES Marazul Charters, Inc. and its employees, shareholders, officers, directors, successors, agents, and assigns, neither own nor operate any person or entity which is to, or does, provide goods or services for these trips or tours. Because Marazul Charters, Inc does not maintain any control over the personnel, equipment, or operations of these suppliers, Marazul Charters, Inc assumes no responsibility for and cannot be held liable for any personal injury, death, property damage, or other loss, accident, delay, inconvenience, or irregularity which may be occasioned by reason of (1) any wrongful, negligent, willful, or unauthorized acts or omissions on the part of any of the tour suppliers, or other employees of agents, (2) any defect in or failure of any vehicle, equipment, instrument owned, operated or otherwise by any of these suppliers, or (3) any wrongful, willful, or negligent act or omissions on any part of any other party not under the supervision or control of the Operator (4) sickness, weather, strikes, hostilities, wars, terrorist acts, acts of nature, local laws or other such causes. All services and accommodations are subject to the laws and regulations of the country in which they are provided. Marazul Charters, Inc is not responsible for any baggage or personal effects of any individual participating in the trips arranged by Marazul Charters, Inc. Individual travelers are responsible for purchasing a travel insurance policy, if desired, that will cover some of the expenses associated with the loss of luggage or personal effects. LIABILITY RELEASE STATEMENT I have read the disclaimer stated above and I hereby release and discharge Marazul Charters, its agents, employees, officers, directors, shareholders and successors from and against any and all liability arising from my participation in this trip. I agree that this release will be legally binding upon myself, my heirs, successors, assigns and legal representatives; it being my intention to fully assume all risk of travel and to release Marazul Charters, Inc from any and all liabilities to the maximum permitted by law. Signature Name Dates of travel Address (Street) City State Zip

5 Professional Certification of Travel to Cuba Under a General License Effective January 16, 2015 PLEASE RETURN TO via fax OR travel@academic-travel.com. I understand that I must keep full and accurate records of the transactions I engage in related to this travel for 5 years from the date of the transaction. I have read the section of the Cuban Assets Control Regulations, 31 C.F.R. Part 515 that is checked off below (for a complete list of the requirements and restrictions for travel to Cuba (go to ) and I certify that I satisfy all the conditions for traveling to Cuba identified in that section of the regulations OR I have provided Marazul Charters, Inc. with a copy of my specific license. I understand I must also have a valid Cuban entry document to travel. SIGNATURE NAME (please print) DATES OF TRAVEL ADDRESS - Street CITY, STATE, ZIP TEL / SECTION OF THE REGULATIONS / GENERAL LICENSE THAT AUTHORIZES MY TRAVEL TO CUBA: 31 C.F.R (a)(1) Professional research in Cuba Travel-related transactions and such additional transactions as are directly incident to professional research are authorized provided that: (i) the purpose of the research relates to the traveler s profession, professional background, or area of expertise, including area of graduate-level full-time study; (ii) That the traveler does not engage in recreational travel, tourist travel, travel in pursuit of a hobby, or research for personal satisfaction only; and (iii) the schedule of activities does not include free time or recreation in excess of that consistent with a full-time schedule of professional research. 31 C.F.R (a)(2) Professional Meetings in Cuba Travel-related transactions and such additional transactions as are directly incident to professional research are authorized provided that: (i) the purpose of the meeting or conference is not the promotion of tourism in Cuba; (ii) the purpose of the meeting directly relates to the traveler s profession, professional background, or area of expertise, including graduate-level full-time study; (iii) and the travel does not engage in recreational travel, tourist travel, or travel in pursuit of a hobby; and (iv) the schedule of activities does not include free time recreation in excess of that consistent with a full-time schedule of attendance at professional meetings and conferences. I agree to adhere to the guidelines as outlined in the Section of the Regulations / General License that authorizes my travel to Cuba. SIGNATURE DATE NAME (PLEASE PRINT)

People-to-People Travel with the Center for Cuban Studies

People-to-People Travel with the Center for Cuban Studies In addition to this application, please send us a copy of your passport information page. Please list the Name and Dates of Program you wish to