America Telugu Sambaralu

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First Name : *

Last Name : *

Email Address: *

Phone Number: *

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Spouse First Name :

Spouse Last Name :

Address: *

City: *

State: *

Zip: *

Alumni:

Self:	College/University
Spouse:	College/University

Family Members (Unmarried Children and Dependents):	Please select the age group applicable.

Referred by :

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	Registration		Number	Total
	Single Adult	100 / person
	Single Adult without food	40 / person

	Couple (Wife & Husband)	160 / couple

	Children (age 7-17, free for 6 & under)	80 / person

	Student * / Visitor / Senior Citizen *	80 / person
	Student without food	20 / person

	CME	50 / person

	July 4^th EPCOT Party (age 18 and over)	40 / person

	Banquet [July 2^nd] (Donors: Add additional banquet tickets only)	50 / person

	NATS Membership (free for all donor categories)	50

Total Amount: (Sum of all the amounts above)
* Student id required copy of valid visa required * age 65 or over
Note: Registration includes admission to all Sambaralu programs (except CME) on July 3 and 4 at the Convention Center and lunch and dinner on July 3 and 4.

Donor Categories		Total Amount	Benefits

	Donor	$ 1,000 - $ 2,499	2 Adult Registrations, 2 Child Registrations, 2 Banquet, NATS membership

	Patron	$ 2,500 - $ 4,999	4 Registrations, 4 Banquet, 1 CME, 1 Hotel Room for 3 nights, NATS membership

	Benefactor	$ 5,000 - $ 9,999	4 Registrations, 4 Banquet, 2 CME, 2 Hotel Rooms for 3 nights, NATS membership

	Grand Benefactor	$10,000 and above	4 Registrations, 4 Banquet, 2 CME, 1 Hotel Suite for 3 nights, NATS membership