(908) 479-1341
shaila@audiopedics.com
"Personalized Intervention"
REGISTRATION
Please mail in your registration to -Audiopedics LLC
or
call Ms.Akila Rajappa at 1-(646)270-1296
or
Dr.Shaila Nanjundiah at (908)-479-1341
FEES
Early Bird Registration $75 (before June 1, 2009)
Late Registration (after June 1, 2009) $ 90
Note: Members of the Academy of Indian Music,
South Plainfield, NJ can avail of 10% discount
REGISTRATION FORM
All Fields Required. Please Print Clearly
Full Name
:________________________________________________________________________
First
Middle Initial
Last
Mailing Address
:________________________________________________________________________
Street
City
State
Zip Code
Daytime Phone
:(____)________________________________________
Fax Number
:(____)________________________________________
E-Mail Address
:______________________________________________
Educational Background
:______________________________________________
Musical Interest, background and experience (please describe)
:______________________________________________
Payment Information
If paying by check, please make payable to Audiopedics, LLC and mail the registration form to: AUDIOPEDICS, LLC 13 Melanie Lane, Phillipsburg, NJ 08865. You may fax the registration to (908)-454-4482. If paying by credit card, please call Shaila at (908)-479-1341 or Akila at (646)270-1296.
CREDIT CARD INFORMATION:
NAME OF THE CARD HOLDER:
NUMBER:
EXPIRATION DATE:
CVC number at the back of your card:
TYPE (visa/MC/AMER-EXP):