Japan-America Society of Indiana

and the Indiana Japan Chamber


Dinner with Dr. Ei-ichi Negishi

Tuesday, February 22, 2011
Hyatt Regency Indianapolis

Registration Deadline: Friday, February 18, 2011.  No refunds after this date.

*Please indicate if the attendee is a student or a teacher.　

お申込締切：　2011年2月18日(金曜日)　この日以降のご返金はいたしかねますのでご了承ください。
ご参加者が学生または教師の場合は、その旨職業欄などにご記述ください。

Contact Information　(お申込者)

Please List Guest Names:　(追加のご参加者)

Registration Fees

Individual (個人)       $50
Table of 8 (8人掛けテーブル)             $400

Student/Teacher Sponsorship

Companies are encouraged to sponsor the attendance of teachers and students of the sciences or of the Japanese
language.

Yes, We will be sponsor sponsoring the attendance of following number of teacher(s) or student(s) for $50 / person


If you are sponsoring the attendance of teacher(s) or student(s), please make sure that when you check out, the total number of attendees that you pay for includes yourself and the number of teacher(s)/student(s) you will be sponsoring. For example, if you will be coming alone and you will sponsor the attendance of 2 teachers/students, plese pay for 3 individuals when you check out.

Payment Method

Mail Check
Make checks payable and remit to:　(下記住所まで、小切手をお送りください):　
Japan-America Society of Indiana, Inc
Union Station
39 West Jackson Place, Suite 50
Indianapolis, IN 46225
Online Credit Card　
If you celect to pay by credit card you will be taken to a form immediately after this form has been successfully submitted. 　
(下記、お申込みボタンをクリックした後、オンラインでのお支払い画面に進みます)
Send me an invoice
We will send you an invoice soon. 　
　　(ご請求書をお送りさせていただきます。)