Registration

Registration Form

10th Bangamela 2008
An Annual Festival of Bengali Culture
Sponsored By : Mid America Bengali Association
July 18-20, 2008


1.	Primary Registrant
Last Name:	*
First Name:	*
Address:
Line2:
City:
State:	*
Zip:
Home Phone:	* (123-456-7890)
Cell Phone:	(123-456-7890)
Email:	*
Registrant Category:
	Additional Registrants (names are required):	(Kid's age as of July 1, 2008)
2:
3:
4:
5:
6:

Select Donation Category:	$150 Contributor $300 Donor $500 Patron $1000 Grand Donor $2000 Grand Patron $5000 Special Sponsor None

	payment by check please print and mail to: P O Box 271, Lewis Center OH 43035
	Please verify all information before submit