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American-Israel Chamber of Commerce, Southeast Region
2012 Eagle Star Awards Gala
Registration Form

Please complete and print this form and mail with your check to:

American-Israel Chamber of Commerce, Southeast Region
400 Northridge Road, Suite 250
Atlanta, Georgia 30350
(404) 843-1416

2012 Eagle Star Awards Gala Registration Form

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

Last Name:
Title: Company:

Address:

Address:

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

Registration Fee (Check all applicable boxes)

Please select here:
Price
Quantity
Total
 Purchase Ticket $95.00
 $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 * $    ______  
I would like to be a sponsor $    ______  
   
Total amount for payment:

For ticket purchase/non tax deductible contribution please make your check payable to American-Israel Chamber of Commerce, SE Region

* - Please make your Tax Deductible ticket purchase ($60 eligable for deuction)/ contribution payable to the American Israel Educational Institute.

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