Institute of the Americas Anniversary Dinner Gala Registration Form

25TH ANNIVERSARY REGISTRATION FORM
Hilton La Jolla Torrey Pines

Pricing:
November 15 Conference at the Institute of the Americas:
• Free registration for dinner ticket holders
• $150 for non-dinner attendees
• $50 for teachers and professors
• Student scholarship (conference only), contact Sherry White

November 15 Anniversary Dinner: (Dinner Ticket includes Conference Admission)
• $ 400 Patron Ticket ( include private reception with Zedillo)
• $ 250 Friend Ticket
• $1,900 Friend Table of 8
• $2,500 Founders Society Donation-without attending dinner
• $3,000 Patron Table of 8 ( include private reception with Zedillo)
• $5,000 Founder Table of 8 (honoring Ted Gildred and Dick Atkinson)

Name First name Last name

Telephone, Facsimile, Email Telephone Facsimile Email

Company Information (optional) Title Company

Address Address1 Address2 City State Zip Code Country

Secretary Information Secretary's Name (optional) Secretary's Email (optional)

Payment details I authorize the Institute to process this charge:
Amount Credit card (select one)

Visa Master card American Express

Credit Card number Expiration Date Name on Card

or I will mail payment to the Institute of the Americas. 10111 North Torrey Pines Rd. La Jolla, CA. 92037
I will attend: (please check all appropriate): Nov.15 conference session Nov.15 anniversary dinner

Founder and Patron dinner ticket holders attend the VIP reception, receive preferential seating, and are recognized in the dinner program. Friend ticket holders attend the Friends reception and the dinner. All ticket holders receive a complimentary registration to the Nov.15 conference.

Sponsors receive significant benefits. For information, please contact Sherry White or by phone at 858.453.5560 ext. 114.

25TH ANNIVERSARY REGISTRATION FORM Hilton La Jolla Torrey Pines

25TH ANNIVERSARY REGISTRATION FORM
Hilton La Jolla Torrey Pines