VPA CONVENTION 2000

REGISTRATION FORM IRS TAX ID 31-1529941

Name ___________________________________________________________

Spouse ___________________________________________________________

Children ___________________________________________________________

___________________________________________________________

Guest ___________________________________________________________

Address ___________________________________________________________

___________________________________________________________

Phone ________________________ E-mail ________________________

Total # Attendees ______________

REGISTRATION FEES:
Note: Registration fees includes two breakfasts, two lunches, three dinners, and convention fees.

Single $100.00 ______________

Family of 4/5 $250.00 ______________ ( Persons above 25 Yrs and working are encouraged to register individually.)

Guest $50.00 Per day ______________

Total ______________

Please mail this completed registration form along with your fee payable to VPA CONVENTION 2000 to :

Dr. Raja P. Gowda

741 Royal Dublin Ln.

Dyer, IN 46311

Phone: 219-865-0388

ENCLOSED:
Amt. for Registration _______________________

Amt. for Advertisement _______________________

(Please include your message and a recent photo)

Amt. for donation _______________________