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“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: ________________