| Ainm/ Name: |
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| Sloinne/ Surname: |
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| Seoladh/Address: |
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| Uimhir Gutháin / Telephone No: |
(Baile/Home) |
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(Obair/Work) |
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| Seoladh Ríomhphoist / Email Address: |
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| Slí Bheatha / Occupation: |
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| Tá éarlais 100 euro
faoi iamh cun áirithint a dhéanamh ar: I enclose a 100 euro
deposit to reserve a place on: |
| Ainm an Chúrsa / Title of Programme: |
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| Dátaí / Dates: |
Ó / From:_____ /
_____ / _____ |
Go / To:_____ / _____ /
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| Áirithint ar Lóistín /
Accommodation preference: |
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| L & B / B&B |
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| Féinfhreastal / Self-catering |
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| Socrú eile / Own arrangement |
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| Siniú / Singature: |
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| Dáta / Date: |
_____ /
_____ / _____ |