to read the full brochure pdf - American Association of Physicians of

IC
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NY
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AAPI-QLI
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American Association Of
Physicians Of Indian Origin
www.aapiqli.org
Corporate Marketing Opportunities
19th Annual AAPIQLI Convention
Celebrating 19 Years of Excellence
Sunday Dec. 7, 2014
9:00 am to 1:00 pm
CME Lectures & Educational Seminar
Saturday Dec. 13, 2014
5:30 pm to 11:30 pm
Annual AAPI-QLI Convention
Akbar Restaurant
Huntington Hilton, Long Island
2 South Street, Garden City, NY 11530
(516) 357-8300
598 Broad Hollow Road, Melville, NY 11747-5002
(516) 845-1000
Our Honorees for 2014
Samin K. Sharma, MD
Uma Mysorekar, MD
Ashok Shaha, MD
Ganesh J. Bhat, MD
FACC, FSCAI
Director of Clinical Cardiology & Intervention
Dean of International Clinical Affiliations
President of the Mount Sinai Heart Network
Zena & Michael A. Wiener Professor Medicine,
Cardiology
Retired Obstetrician/Gynecologist
President of the Hindu Temple Society of
North America in Flushing, NY.
Professor of Surgery,
Jatin P. Shah Chair in Head & Neck Surgery,
Memorial Sloan Kettering Cancer Center, NY
Co-Founder, Atlantic Dialysis Management Services
Chancellor, Xavier University School of Medicine
Member, NY State Public Health & Health Planning Council
Chairman, Committe on Health Personnel and
Interprofessional Relations, NYSDOH
IC
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AAPI-QLI
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Executive Committee
President
Ajay K. Lodha, MD
President Elect
Madhu Korrapati, MD
Vice President
Vaijinath Chakote, MD
Secretary
Rakesh K. Dua, MD
Treasurer
Jagdish K. Gupta, MD
Immediate
Past President
Tarun Wasil, MD
Board of Trustees
Shashi S. Shah, MD Chairman
Bal Gilja, MD
Jagan Pahuja, MD
Krishan Kumar, MD
Mohinder P.Gupta, MD
Rashmikant Baxi, MD
Satish K Anand, MD
Sharwan K Bagla, MD
Sunil Mehra, MD
Tarun Wasil, MD
TKS Rao, MD
Members at Large
Abhay Malhotra, MD
Anil Kanth, MD
Arun Aggarwal, MD
Gagan Gulati, MD
Himanshu Pandya, MD
Holalkere Rajgopal, MD
Inderpal Chhabra, MD
Paresh C Kothari, MD
Raj Bhayani, MD
Rajendra Jinna, MD
Swaran Gupta, MD
American Association Of Physicians Of
Indian Origin of Queens & Long Island, Inc.
7 Oakridge Lane, Roslyn, NY 11576
www.aapiqli.org
PROGRAM SCHEDULE:
Sunday, December 7, 2014
CME Lectures & Educational Sponsor Seminar
at Akbar Restaurant
9:00 am to 9:30 am - Breakfast
9:30 am to 11:00 am - CME / Educational Seminar
11:00 am to 11:15 am - Tea Break
11:15 am to 1:00 pm - CME / Educational Seminar
1:00 pm - Lunch
Saturday, December 13, 2014
at Huntington Hilton
12:30 pm to 5:00 pm - Professional Singles Speed Dating Event
5:30 pm to 7:00 pm - Cocktail Reception
7:00 pm to 11:30 pm - Cultural Program,
Felicitation of Honorees, Dinner &
Bollywood Style Entertainment
President
Convention Chair
Ajay K. Lodha, MD
Raj Bhayani, MD
[email protected]
347-865-7906
[email protected]
718-249-9383
Convention Co-Chair
Convention Co-Chair
Himanshu Pandya, MD
Holalkere Rajgopal, MD
[email protected]
917-903-3885
[email protected]
516-305-9030
Advisory Board
Amit Power, MD
Chairman
Dayanand Huded, MD
Narendra Hadpawat, MD
Rajiv Datta, MD
Sukhvinder S. Ranu, MD
Vinni Jayam, MD
MSRF
Prachi Dua, MD
YPS
Jigar Patel, MD
Preeti Mehta, MD
Ajay K. Lodha, MD
President
Shashi S.Shah,MD
Chair,Board Of Trustee
Convention Committee
Raj Bhayani, MD
Convention Chair
Himanshu Pandya, MD
Holalkere Rajgopal, MD
Convention Co-Chair
Fundraising
Rajiv Datta, MD Chair
Amit Powar, MD Chair
Vaijinath Chakote, MD Co-Chair
Arun Aggarwal, MD
Tarun Wasil, MD
Sunil Mehra, MD
Vinni Jayam, MD
Dayanand Huded,MD
Anil Kant,MD
Inderpal. Chhabra, MD
Abhay Malhotra, MD
Krishan Kumar, MD
Madhu Korrapati
Amy Nagarajan Shah,MD
Food Committee
Rakesh Dua, MD Chair
Dayanand Huded, MD Co-Chair
Host Committee
Satish K. Anand, MD Chair
Madhu Korrapati, MD Chair
Abhay Malhotra, MD Co-Chair
Rajendra Jinna, MD Co-Chair
Editorial and Publishing
Tarun Wasil, MD Chair
Inderpal Chhabra, MD Co-Chair
CME
T.K. Sreepada Rao, MD Chair
Sharwan K Bagla, MD Chair
Vinni Jayam, MD Chair
Anil Kant, MD Co-Chair
Awards / Honorees
Rasmikant Baxi, MD Chair
Narendra Hadpawat, MD Co-Chair
Sunil Mehra,MD Co-Chair
Jagdish Gupta,MD Co-Chair
Booth
Madhu Korrapati, MD Chair
Rakesh Dua, MD Chair
Paresh Kothari, MD Co-Chair
Sheetal Seth, MD Co-Chair
Entertainment
Jagdish Gupta, MD Chair
Bhavani Srinivasan, MD Co-Chair
Charitable Committee
Mohinder P.Gupta, MD Chair
Arun Aggarwal, MD Co-Chair
Reception Committee
Sunil Mehra, MD Chair
Jagan Pahuja, MD Chair
Sharwan K.Bagla, MD Chair
Satish Anand, MD Chair
Sukhvinder S. Ranu, MD Chair
Narendra Hadpawat, MD Chair
Media & Public Relations
Krishan Kumar, MD Chair
Bal K. Gilja, MD Co-Chair
Rajendra Jinna, MD Co-Chair
Registration
Himanshu Pandya, MD Chair
Gagan Gulati, MD Co-Chair
Swarn Gupta, MD Co-Chair
Paresh Kothari, MD Co-Chair
Decoration
Smita Lodha, MD
Dipali Pandya, DMD
Asha Dua, MD
Jyoti Chakote, MD
Pushpa Shah, MD
Seema Wasil
Sireesha Korrapati
Website & Database
Inderpal. Chhabra, MD Chair
Tarun Wasil, MD Chair
Amit Powar, MD Co-Chair
MSRF
Prachi Dua, MD Chair
YPS
Jigar Patel, MD Chair
Preeti Mehta, MD Co-Chair
--------------------------------------#------------------------------------------#----------------------------------Print or type
Registration Form
You can register online at: WWW.AAPIQLI.ORG
(Tax I.D.: 113267715) C5013C Non Profit Tax Organization
Sponsorship Opportunities
q
2014 Grand Sponsor: $35,000.00 -
q
Diamond Sponsor: $25,000.00
Legend Securities, Inc.
Gold Sponsor: $10,000.00
q
Platinum Sponsor: $15,000.00
q
Signage at Registration & Ballroom
Tickets (10) for Gala Dinner Booth, Front Inside Cover Convention Souvenir Book
Signage at Registration
Tickets (6) for Gala Dinner
Booth, Back Inside Cover Convention Souvenir Book
Silver Sponsor: $5,000.00
q
Corporate Signage at registration
Tickets (4) for Gala Dinner & 1 Gold Page
Corporate Signage at registration
Tickets (2) for Gala Dinner & 1 Silver Page
Souvenir Advertising:
Gold Page: $2,000.00
Full Page: $1000.00
q
q
W-9
Form
(Rev. August 2013)
Department
of the$2,000.00
Treasury
q Booth:
Internal Revenue Service
Silver Page: $1,500.00
Half Page $500.00
q
q
Request for Taxpayer
Identification Number and Certification
Booth:
Print or type
See Specific Instructions on page 2.
(2:00 pm onwards. Includes one 4’x6’ table & two chairs. Exhibitor will be responsible for Internet, Decoration,
Name (as shown on your income tax return)
Lighting, Security & other requirements.)
AAPI OF QUEENS AND LONG ISLAND, INC.
Corporate
Sponsor:
Business name/disregarded entity name, if different
from above
q
Corporate Table for 10 guests: $3,000.00 (Signage on Table)
Check appropriate box for federal tax classification:
AAPI-QLI
is proud to host this event to raise funds for charitable causes and we look forward for your support.
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Ex
Trust/estate
Registration for Gala Event:Members & Spouse $100.00/Person | Non-Members $125.00/Person
Registration
for Singles
$50.00
- Singles
Event only.
Limited
liability Event:
company.
Enter the
tax classification
(C=C corporation, S=S corporation, P=partnership) ▶
$100.00 - Singles event & AAPIQLI Annual Gala, AAPIQLI YPS & MSRF members only (limit first 20 registrants).
Ex
Ex
co
✔
TAX EXEMPT CHARITABLE ORGANIZATION
Other (see instructions) ▶
First Name:_____________________Last:_
__________________________Company:___________________________
Address
(number,
street,
and
apt.
or
suite
no.)
Requester’s name and
Title/Position:_____________________________________Email:___________________________________________
Address:_________________________________________City:__________________State:________Zip:___________
7 OAKRIDGE LANE
City, state, and ZIP code
Payment Information: q Check for $___________ payable to AAPIQLI or q Charge $___________ to my
NY 11576
q VisaROSLYN,
q Master Card
q Discover q AMEX Card No:___________________ Exp.___/___ Sec. Code (CVV):______
List
account
number(s)
here (optional)
Billing street address:_________________________________________________________
Billing Zip:___________
Name on card:_____________________________________________________ Signature:_____________________
W-9
PartCheck
I
Taxpayer
Identification
Number
(TIN)
Make
Payable
to: AAPIQLI
or Register Request
online at www.aapiqli.org
and pay by Pay Pal
Form
for Taxpayer
Give Form to the
SocialDo
securi
Enter
your
TIN
the appropriate
box. The
TIN provided
must
match
the name given on the “Name” linerequester.
not
(Rev.to:
August
2013)
Mail
Ajay
K.inLodha
MD, President
7 Oakridge
Lane,
Roslyn,
NY
11576
Identification
Number
and
Certification
to Department
avoid backup
withholding. For individuals,
this is your
social security
number (SSN). However, for a send to the IRS.
of the Treasury
Internal Revenue Service
resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
shown on your income tax return)
entities,Name
it is (as
your
employer identification number (EIN). If you do not have a number, see How to get a
Give Form to the
Form
AAPI OF
INC.
for Taxpayer
TIN on page
3. QUEENS AND LONG ISLAND, Request
requester. Do not
name/disregarded entity name, if different from above
(Rev. AugustBusiness
2013)
Employer ide
Identification
and
Certification
Note. Ifofthe
account is in more than
one name, seeNumber
the chart on
page
4 for guidelines on whose
send to the
IRS.
Department
the Treasury
Internal
Revenue
number
toService
enter.
Exemptions (see instructions):
Check
appropriate
box
for
federal
tax
classification:
Name (as shown on your income tax return)
1 1
–
C Corporation
S Corporation
Partnership
Trust/estate
Individual/sole proprietor
AAPI OF QUEENS AND LONG ISLAND, INC.
Exempt payee code (if any)
------------------------#------------------------------------------#----------------------See Specific Instructions on page 2.
See Specific Instructions onPrint
pageor2.type
W-9
Part
II name/disregarded
Certification
Business
entity name, if different from above
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
▶
Exemption from FATCA reporting
Under penalties of perjury, I certify that:
code (if any)
1. The
number
this
is my TAX
correct
taxpayer
identification
number (or I am waiting
for a(see
number
to be issue
▶
Exemptions
instructions):
✔appropriate
Check
box
for on
federal
taxform
classification:
EXEMPT
CHARITABLE
ORGANIZATION
Other shown
(see
instructions)
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
C Corporation
S Corporation
Partnership
Trust/estate
Individual/sole
2. I am not
subjectproprietor
to backup withholding
because:
(a) I am exempt
from backup
withholding, or (b) I have not been not
7 OAKRIDGE
Exempt payee
code (if any)
Service
(IRS) thatLANE
I am subject to backup withholding as a result of a failure to report all interest
or dividends,
or (c) th
City,
state,
and
ZIP
code
Limited
liability company.
Enter the
tax classificationand
(C=C corporation, S=S corporation, P=partnership) ▶
Exemption from FATCA reporting
no longer
subject
to backup
withholding,
ROSLYN, NY 11576
code (if any)
List
account
number(s)
(optional)
3. I am
a U.S.
citizen
orhere
other
U.S. person
and ORGANIZATION
✔ Other (see instructions) ▶
TAX (defined
EXEMPT below),
CHARITABLE
4. The
FATCA
code(s)
entered
on no.)
this form (if any) indicating that I am exemptRequester’s
from FATCA
reporting
is correct.
Address
(number,
street, and
apt. or suite
name and
address (optional)
Part I
Taxpayer Identification Number (TIN)
Certification
instructions.
You must cross out item 2 above if you have been notified by
the
IRS
that
you are currently s
7 OAKRIDGE
LANE
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
City, state,
ZIP code
because
youand
have
failed to
all interest
and
dividends
on your
taxHowever,
return. for
For
to avoid
backup
withholding.
Forreport
individuals,
this is your
social
security number
(SSN).
a real estate transactions, item 2 does n
interest
paid,
acquisition
secured
of debt, contributions– to an individual
retirem
–
resident
alien, sole
proprietor,or
or abandonment
disregarded entity,of
see
the Part Iproperty,
instructions cancellation
on page 3. For other
ROSLYN,
NY 11576
entities, it is
your employer
identification
numberand
(EIN).
If you do notyou
haveare
a number,
see How to
a the certification, but you must provid
generally,
payments
than interest
dividends,
not required
toget
sign
List account
number(s) other
here (optional)
TIN on page 3.
instructions
on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
Sign
number
Signature Identification
of
Part
I to enter.
Taxpayer
Number (TIN)
Here
person ▶ box. The TIN provided must match the name given on the “Name” line
Enter
your TIN inU.S.
the appropriate
Employer identification number
1 1
7 7 1 5
– 3 2 ▶6
Date
Social security number
to avoid
backup
withholding.
For individuals, this is your social security number (SSN). However, for a
Part
II
Certification
share of eff
resident
alien,
sole proprietor,
disregarded
–
Under
penalties
of perjury, or
I certify
that: entity, see the Part I instructions on page 3. For other withholding tax on– foreign partners’
General Instructions
IC
N
NY
IAN
GI
★ AM
PH
YS
AAPI-QLI
★
OF
N ASSOCIATI
ON
ICA
R
E
S OF INDIA N
OR
I
American Association Of
Physicians Of Indian Origin
Professional Singles
Speed Dating Event
www . aapiqli . org
19th Annual AAPIQLI Convention
Registration - 12:30 pm
Singles Event - 1:00 pm to 5:30 pm
Registration Online:
www.aapiqli.org
Registration Fee:
$50.00 - Singles Event only
$100.00 - Singles event and AAPIQLI annual gala
AAPIQLI YPS and MSRF members only (limit first 20 registrants).
For information:
Email: [email protected]
Raj Bhayani, MD
Tel.: 718.249.9383
Kusum Punjabi, MD
Tel.: 732.429.5752
Saturday Dec 13, 2014
Huntington Hilton
Long Island
598 Broad Hollow Road
Melville, NY 11747-5002
516-845-1000

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