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

Complete and print this form, including your credit card information or
a check payable to American-Israel Chamber of Commerce, and mail or fax to:

Aaron Bernstein
American-Israel Chamber of Commerce, Southeast Region
1150 Lake Hearn Drive, Suite 130
Atlanta, Georgia 30342
(404) 843-1416

 

First Name: (as it will appear on your name badge)	Last Name:
Title:	Company:
Address: Address:
City:	State: Zip:
Telephone:	Fax:
Email Address:

Please select here:		Price	Quantity	Total	Online Payment Option
Single Attendee		$75.00	1 2 3 4 5 6 7 8 9		Registration Closed
$180 Contribution (one ticket) *		$180.00	1		Registration Closed
$360 Contribution (two tickets) *		$360.00	1		Registration Closed
$540 Contribution (three tickets) *		$540.00	1		Registration Closed
	I would like to make a contribution to support the work of the American Israel Educational Institute *	$    ______			Registration Closed
Total amount for payment:
* - Please make your Tax Deductible contribution payable to the American Israel Educational Institute.
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): If you are paying online, please state "Paid Online" in place of the credit card number   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.