|
First Name:
|
|
|
Last Name:
|
|
|
Address:
|
|
|
City:
|
|
|
State:
|
|
|
Zip Code:
|
|
|
Phone:
|
|
|
Fax:
|
|
|
E-mail:
|
|
|
Name(s) and Age(s) of Children:
|
|
|
Membership type:
Lifetime membership
|
|
Individual - $250
|
Family - $500
|
|
Regular membership:
|
|
Family member - $50
|
Individual member - $25
|
|
Student member - $10
|
Senior citizen - $10
|
|
Membership for Organization:
|
|
Annual Membership - $50
|
|
Total Amount due
|
Check #
(If Paying by check)
All checks to be sent to :
India Culture Center (ICC)
8888 West Belfort, Suite 210D
Houston TX 77031
|
|
Comments/I would like to Volunteer in the Following Areas/Activities: |
|
|
I here by authorize the India Culture Center to Charge to my Credit Card
|
|
Name as on the Card:
|
|
Credit Card # Exp.
|
|
Master Card Visa American Express Discover Card Dinner's Club
|
|
Please check if credit card billing address same as business address.
If different, please write the address in comments. .
|
