IMCSTL Annual Diwali Gala 2022 October 29th, 2022 Free for Life/Annual Members & Spouses Free for Medical Students, Residents and Fellows Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is attending the Diwali Gala (Saturday Oct 29th evening)* Self Spouse Other Not Attending Total attendees for Saturday dinner including you* Additional Guests* Are you a Member of IMCStL?* Yes No Are you bringing any Non-member Guests? Yes No Non-Members/Guests* Price: $50.00 Quantity: Guest Information*First NameLast Name Click on (+) to add another guest.In order to register please pay Annual Membership dues. Your Diwali Gala registration will be included in your membership fees for you and your spouse.Annual Membership* Price: $100.00 Quantity: Are you bringing any Non-member Guests? Yes No Registered Non-Members/Guests* Price: $50.00 Quantity: Guest Information*First NameLast Name Click on (+) to add another guest.Total $0.00 Please Note: If you are paying your annual membership dues during the registration process. After you Submit this form, you will be directed to PayPal page to complete payment information. Your registration will not be complete without completing payment on PayPal. If you do not have PayPal just continue as guest and you will be able to pay directly with your credit card. Thank You.EmailThis field is for validation purposes and should be left unchanged. Δ
