IC

NY
IAN

PH

YS

GI

AM

AAPI-QLI

OF

N ASSOCIATI
ON
ICA
ER

S OF INDIA N

OR

AMERICAN ASSOCIATION OF
PHYSICIANS OF INDIAN ORIGIN

WWW.AAPIQLI.ORG
CORPORATE MARKETING OPPORTUNITIES

19th Annual AAPI-QLI Convention

Celebrating 19 Years of Excellence

SUNDAY DEC. 7TH, 2014

CME Lectures & Educational Seminar
Akbar Restaurant

SATURDAY DEC. 13TH, 2014

Huntington Hilton, Long Island
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

IAN

S OF INDIA N

NY

GI

PH

YS

AAPI-QLI

OF

AM

N ASSOCIATI
ON
ICA
R
E

OR

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
Raj 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 7th 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 12:45 pm - CME / Educational Seminar
12:45 pm - Lunch
Saturday, December 13th 2014
at Huntington Hilton

1:00 pm to 5:00 pm - Professional Singles Speed Dating Event

5:30 pm to 7:00 pm - Cocktail Reception
7:00 pm to Midnight - Cultural Program,
Felicitation of Honorees, Dinner &
Bollywood Style Entertainment
President

Convention Chair

Ajay K. Lodha, MD

Raj Bhayani, MD

aapiqlipresident@gmail.com
347-865-7906

drbhayaniraj@gmail.com
718-249-9383

Convention Co-Chair

Convention Co-Chair

Himanshu Pandya, MD

Holalkere Rajgopal, MD

pandyamd@yahoo.com
917-903-3885

kingopal@hotmail.com
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
Raj 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
Raj 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

IC

IAN

S OF INDIA N

NY

GI

--------------------------------------#------------------------------------------#---------------------------------- AM
PH

YS

AAPI-QLI

OF

N ASSOCIATI
ON
ICA
ER

OR

AMERICAN ASSOCIATION OF PHYSICIANS OF

INDIAN ORIGIN OF QUEENS & LONG ISLAND, INC.
7 Oakridge Lane, Roslyn, NY 11576
Phone: 347-865-7906 E-Mail: Aapiqlipresident@gmail.com

WWW.AAPIQLI.ORG

REGISTRATION FORM
You can register online at: WWW.AAPIQLI.ORG
(Tax I.D.: 113267715) C5013C Non Profit Tax Organization

SPONSORSHIP OPPORTUNITIES
q Grand Sponsor: $35,000.00
Signage at Registration & Banner inside Ballroom

Tickets (10) for Gala Dinner
Booth
Back Cover Convention Souvenir Book
q Diamond Sponsor: $25,000.00
Signage at Registration & Ballroom
Tickets (10) for Gala Dinner
Booth
Front Inside Cover Convention Souvenir Book

q Platinum Sponsor: $15,000.00

Signage at Registration
Tickets (6) for Gala Dinner
Booth
Back Inside Cover Convention Souvenir Book

q Gold Sponsor: $10,000.00

Corporate Signage at registration
Tickets (4) for Gala Dinner
1 Gold Page Convention Souvenir Book

q Silver Sponsor: $5,000.00

Corporate Signage at registration
Tickets (2) for Gala Dinner
1 Silver Page Convention Souvenir Book

q
q

Gold Page: $2,000.00

Full Page: $1000.00

SOUVENIR ADVERTISING:
q Silver Page: $1,500.00
q Half Page $500.00

BOOTH:
q Booth: $2,000.00 (Exhibit 2:00 pm onwards. Includes one 4x6 table & two chairs. Exhibitor will be responsible for Internet, Decoration, Lighting, Security & other requirements.)
q

CORPORATE SPONSOR:
Corporate Table for 10 guests: $3,000.00 (Signage on Table)

AAPI-QLI is proud to host this event to raise funds for charitable causes and we look forward for your support.

Registration:
Members & Spouse $100.00/Person
Non-Members $125.00/Person
First Name:________________Last:______________________Company:_____________________
Title/Position:_____________________________Email:___________________________________
Address:_________________________________City:______________ State:_____ Zip:_________
Payment Information:
q Check in U.S. dollars for $______________________________________ payable to AAPIQLI
q Charge $_______________________ to my qVisa qMaster Card qDiscover qAMEX
Card No:___________________________ Exp. Date______/______ Security Code (CVV):_____
Billing street address:_________________________________________ Billing Zip:___________
Name on card:____________________________________ Signature:______________________
Make Check Payable to: AAPIQLI or Register online at www.aapiqli.org and pay by Pay Pal
Mail to: Ajay K. Lodha MD, President
7 Oakridge Lane, Roslyn, NY 11576
Cell: 347-865-7906 Email: aapiqlipresident@gmail.com

IC

IAN

S OF INDIA N

NY

GI

AM
PH

YS

AAPI-QLI

OF

N ASSOCIATI
ON
ICA
ER

OR

AMERICAN ASSOCIATION OF PHYSICIANS OF

INDIAN ORIGIN OF QUEENS & LONG ISLAND, INC.
7 Oakridge Lane, Roslyn, NY 11576
Phone: 347-865-7906 E-Mail: aapiqlipresident@gmail.com

WWW.AAPIQLI.ORG

W-9

Form
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give Form to the

requester. Do not
send to the IRS.

Name (as shown on your income tax return)

Print or type
See Specific Instructions on page 2.

AAPI OF QUEENS AND LONG ISLAND, INC.

Business name/disregarded entity name, if different from above

Exemptions (see instructions):

Check appropriate box for federal tax classification:

Individual/sole proprietor

C Corporation

S Corporation

Partnership

Trust/estate
Exempt payee code (if any)

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
Other (see instructions)
Address (number, street, and apt. or suite no.)

Exemption from FATCA reporting

code (if any)

TAX EXEMPT CHARITABLE ORGANIZATION

Requesters name and address (optional)

7 OAKRIDGE LANE
City, state, and ZIP code

ROSLYN, NY 11576
List account number(s) here (optional)

Part I

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.

Social security number

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.

Employer identification number

Part II

1 5

Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.

Sign
Here

Signature of
U.S. person

General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information
about Form W-9, at www.irs.gov/w9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.

Date

8/21/2014

withholding tax on foreign partners share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requesters form if it is substantially
similar to this Form W-9.