Pharmacy Without Prescription - Achat Cialis En France Sans
Transcription
Pharmacy Without Prescription - Achat Cialis En France Sans
“Kavi Sammelan 2015 April 25, 2015” Registration Form Web-site: www.IHA-NEOhio.org MISSION: Preserve, promote and relish the culture of India through Hindi, the language of the Union of India Name: ________________________________________________ Spouse’s Name (if applicable): Address: ______________________________ __________________________________________ ________________________________________________________________ Phone Number: ________________________________________________________ Number of Adults: ______ Sponsor? (Please check one): Number of Children under Five: _____ Platinum ($500 -- 10 Complimentary Tickets) Gold ($200 -- 6 Complimentary Tickets) Silver ($100 -- 4 Complimentary Tickets) Bronze ($50 -- 2 Complimentary Tickets) IHA Member? (Please circle one): Yes No Would like to become IHA Member? Yes No If you would like to become an IHA Member, please fill the IHA Membership Form. Thanks. E-mail: Check Number: ________________________________________ _______________ Bank: ____________________ Donations (per person): Members $25 Students $15 Non-members $30, Children Under Five Free Please make checks payable to: “N.E. Ohio Chapter of IHA” Mailing Address: Ajay Chadda President, IHA-N.E. Ohio 4375 Ridge Crest Akron, OH 44321 ____________________________________________________________________ FOR OFFICIAL USE ONLY Note to the Official: Please fill either A, or B or C, whichever applies. A. Cash Amount: ____________ B. Check Amount: _________________ Check Number: ________________ C. Pre-paid Amount: ___________ Check Number: ________________