INDIAN MEDICAL ASSOCIATION OF GREATER LOS ANGELES
www.imala.net
Annual Convention
October 24, 2009
Sony Studios, 10202 W Washington Blvd, Culver City, CA 90232
REGISTRATION FORM
For life-members, current annual members and one Guest, there is a fee of $ 50 per person if paid before October 14, 2009. 
 After October 14, 2009, life-members and current annual members and one guest pay $ 100 per person at the door.  
For physician non-members, guests of members, and Business Community there is flat fee of $ 150 per person. 
This includes CME, breakfast, lunch and Dinner Gala There is NO additional charge for individual events. 
For Tables, please contact info@imala.net 310-786-7100 Fax 310-472-4459
For medical students, residents and fellows and spouses, there is a fee of $25.00 per person if registered before October 14, 2009. After October 14, 2009, medical students, residents and fellows and their spouses pay $50 at the door.

REGISTRATION DEADLINE: Registration Form and check must be received by October 14, 2009
 Life Member    Annual Member     Non-Members 
  	 Students, Residents, Fellows (Proof required)
Membership Dues:
Life  $750   Annual  $100 
Students Residents and Fellows $50
Enclosed with Registration ________

Name: _____________________
Spouse/Guest Name______________________
Specialty_____________________
Address:______________________________________________________________________
Phone:_______________E-mail:________________Fax: ______________

Please copy, print, fill and mail this form along with your check to: 
IMA of Greater Los Angeles, 
912 Teakwood Rd, Los Angeles, CA 90049.
NON-PROFIT TIN: 95-4393229
The membership form is also available at www.imala.net
For more information, call 310-786-7100.
 METHOD OF PAYMENT
 Check payable to IMA of Greater Los Angeles
VISA	MasterCard		American Express
Credit Card #:_______________________________ Amount________ 
Expiration Date:____________ Security code_______
Billing address ______________________________
______________________________

Signature_______________________________