American-Israel Chamber of Commerce, Southeast Region
2005 Eagle Star Awards Gala
Registration Form

INSTRUCTIONS:
To register online, click here to be taken to a secure site for a credit card transaction.

To register via mail, please print this form, include it with your credit card information or a check made out to American-Israel Chamber of Commerce, and mail it to:

American-Israel Chamber of Commerce, Southeast Region
1150 Lake Hearn Drive, Suite 130
Atlanta, Georgia 30342

To register via fax, please print this form and fax it with your credit card information to
 (404) 843-1416.

First Name:
(as it will appear on your name badge)

 Last Name:
Title: Company:

Address:

 
City:
State: Zip:
Telephone: Fax:
Email Address:

Registration Fee:
Check all applicable boxes.

 Single Attendee $75.00 _____
 Company Table (10 attendees) $750.00 _____
 $180 Contribution (one ticket) $180.00 * _____
 $360 Contribution (two tickets) $360.00 * _____
 $540 Contribution (three tickets) $540.00 * _____
 I would like to make a contribution to support the work of the American Israel Educational Institute $          * _____
   
  Total remitted: _____

* - Pay to the order of American Israel Educational Institute (Click HERE for online payment)

Accepted Methods of Payment:

   Visa   MasterCard   American Express Discover Check (Mail only)

Credit Card Number: ____________________________________Expiration Date: _______

Cardholder's Name (as it appears on card): ______________________________________

Signature: ______________________________________________________________________

Cancellation/Substitutions
If you need to cancel your registration or substitute someone in your place, please notify Shelley Samach at (404) 843-9426 or info@eaglestargala.com.


                                                                                                                   Directions to the event