Application form

Please fill out the form below to purchase a place by cheque.

Step 1: Personal Details

First Name*:

Middle Name:

Surname*:

Date of Birth*:

Email*:

Contact Number*:

Mobile Number*:

Address 1*:

Address 2*:

Town/City*:

County*:

Postcode*:

Step 2: Pilgrimage Details

Travelling from*:

Travelling to*:

Passport Type*:

Passport Number*:

Room Type*:

SingleDouble

If sharing, please add name:

Any Requirements regarding rooms or dietary needs? If so, please fill out this field:

A deposit of £100 is required. Please send cheques payable to "Gospa Mir Pilgrimages" to 11 Killyberry Road, Bellaghy, Co. Derry. Northern Ireland, BT45 8LH