Convention Registration Form(Please Print)

Name:

Title Last First MI

Spouse:

Children & Age:

Address:

City: State: Zip: Country: Cell#:

E-mail: Phone: Fax:

Registration Category (Check all that apply)
Check Donor Category benefits before entering the amounts
Number of Attendees / Early/Person / Intermediate/Person / Late/on site / Total
Before 8/15/2004 / Until 8am EST9/1/2004 / After 8am EST 9/1/2004
( ) Adults (Per Person) / $135.00 / $170.00 / $200.00
( ) Children (6 – 12 Years) / $85.00 / $100.00 / $125.00
( ) Gala Banquet
(Limited Numbers) / $20.00 (For all ages including infants) / $30.00 (For all ages including infants) / $45.00(For all ages including infants)
( ) Continuing Medical
Education (8 Hrs.) / $50.00 / $75.00 / $100.00
( ) Indian Registrants / INR 5000.00
Banquet Charges INR 500.00
Donors (Donations may be Tax deductible)
( ) Kannada Mitra / Complimentary Registration for 2 / $1000.00
( ) Kannada Datha / Complimentary Registration for 4 / $2000.00
( ) Kannada Bandhu / Complimentary Registration for 4; 3 nights accommodation (One Room) / $3000.00
( ) Kannada Premi / Complimentary Registration for 4; 3 nights accommodation (One Room); Half page advertisement / $5000.00
( ) Kannada Kasturi / Complimentary Registration for 4; 3 nights accommodation (One Room); Full page advertisement; Recognition on stage / $10000.00
( ) Charitable Contributions / AKKA Charitable Foundation
( ) AKKA Membership / Become AKKA Member now.
Deduct $10 from Grand Total See below for details
Grand Total ($)
Registration for AKKA Conference includes – Food, Admission to Conference, Souvenir,
Free Entry to Lucky Draw, Free Transportation to Theme Parks
Food Preference: Circle the Number : 1 2 3 4 5 Vegetarian ; 1 2 3 4 5 Non-Vegetarian
AKKA MEMBERSHIP DETAILS Be part of AKKA, and Save $10 from Registration

2 Yr Membership Family $50 Individual $25

Life Family $250 Individual $200
Resort Booking Information.
Please make your own reservation (Rooms are reserved under code AKKA)
Gaylord Palms
6000, W. Osceola Parkway
Kissimee, FL – 34746
407-586-2000 / $85.00 per day/Room
Limited Rooms are reserved for AKKA. Please reserve early.
Visit web site
Discount Rate Valid if Booked before August 15, 2004
Discounted Room rates available from August 31 to Sept 8, 2004
Other Benefits: Contact Person - Mr. Guru Prasad 407-359-6424
Payment Method
Registration Mailing address:
AKKA – WKC 2004
5422, Lynn Road
Tampa, FL33624
Phone (813) 960 5057
FAX Registration to:
(501) 640 9079
Contact Information (Registration Issues):
Mr. BSB Murthy (850) 656 9708
Dr. S. Pallegar (941) 741 8333
Mrs. Prema Rao (863) 646 1102
Mr. D. J. Prakash (813) 961 4958
e-mail: / By Check: Payable to: “AKKA-WKC Orlando, 2004”
By Credit Card: Card Type: Visa MC Amex
Card Holder Name: ______
Card Holder Address (If different): ______
Credit Card Number: ______
Exp Date: ______
Amount Authorized: $______
Signature: ______
Date: ______
Cancellation Policy:
Registrations Non Transferable
80% refund if cancelled before 7/15/04
50% refund if cancelled before 7/31/04
0% refund if cancelled on or after 8/1/04
OFFICE USE:
Date Received: Registration No.: Password:

Convention Badges /Meal Tickets are required for admission to ALL AKKA functions.

Convention Registration Form – Page 1 of 3