First Name
*
Last Name
*
Phone
*
Email
*
Gender
*
Male
Female
Age
*
What nationality do you hold?
*
Which city do you live in?
*
What is your work position?
*
Choose your position
Founder
C Suite
Director
Manager
Executive
Other
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Why are you traveling to Bali?
*
Are you traveling
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Solo
with Friend(s)
with Family
Have you been to Bali before?
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Yes
No
What have you liked or disliked during your last visit?
What do you fear (Insects, Animals, Heights..etc)?
*
Do you smoke?
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Yes
No
Do you drink Alcohol?
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Yes
No
Are you planning to quit drinking on this trip?
Yes
No
Any Allergies?
*
Any Injuries effecting your life?
*
Any health conditions or medications you take?
*
Do you follow a specific diet?
*
Your Fitness Level?
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I don't do sports
I train 3 times a week
I'm very fit, I train 5+ a week
Sports you enjoy?
*
Do you meditate?
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Never
Sometimes
Regularly
Are you ok if you appeared in some of the videos & photos we shot during the trip?
*
Yes
No
We'll use those in marketing materials
Take me to Bali!