Adams Mill Restaurant 

        165 Adams Street 

       Manchester, CT  06042          Exit 62 off I‐84 

          Telephone: (860) 646‐4039  

Saturday Evening: April 27th 2013   Cocktail hour at 5:30 PM followed by Dinner Buffet  

 

 

 

 

$49.00 adults • $25.00 under 13 years old 

RSVP to Master Robert on or before April 20th.  No Entry for Late Registration!     

Email SENSEI@HOUSEOFKOKONDO.COM or call 860.209.4599 

Please make checks payable to IKA, LLC and mail to:  Robert E. Robert • 26 Hooker Drive • West Hartford, CT  06107 

complete registration form on back side 

Be Recognized for your 

Highest Rank of the Year! 

Appetizer Table Assorted Cheese & Vegetables Assorted Crackers • Baby Greens Salad • Dinner 

Buffet with Penne Pasta Ala Vodka • Fresh Oven Roasted Salmon Filet •Sliced Stuffed Chicken Breast 

• Fresh Seasonal Vegetables • Au Gratin Potatoes •Carving Station with Roast Sirloin Beef & Roast 

Pork Loin – Garlic & Rosemary • Coffee •Decaf •Cheese Cake • and Much More! 

• Food • Fun • Demonstration • Food • Fun • Demonstration • Food • Fun • Demonstration • Food • Fun • Demonstration • 

Register On‐line www.kokondoawardsbanquet.eventbrite.com 

REGISTRATION AND PAYMENT MUST BE RECEIVED ON OR BEFORE APRIL 20, 2013

Number Attending Qty $ Qty $ Qty $ Adults (13 years old +)

$49.00 ea Children (under 13 years old)

$25.00 ea TOTAL Full Name

Guest 1 Guest 2 Guest 3 Guest 4

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Child (x)

Last First M.I.

Address:

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Dojo / Rank Information

Dojo Name:

Chief Instructor:

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Payment Information: if paying by check please mail to Robert E Robert • 26 Hooker Drive • West Hartford, CT 06107

Check One

Check Payable to IKA LLC

Visa

MC

AMEX

Credit Card Information

Name on Credit Card

Credit Card Number Expiration Date CVV Security Code

CVV is the last 3 digits on the back of your card. For AMEX it's the 4-digit code on the front side.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  I, ______________________________, authorize IKA, LLC to charge my credit card account in the amount listed above for the 2013 IKA Awards Banquet. I agree to be bound by IKA, LLC policies, terms and conditions, and instructions for this transaction. I authorize this form to be emailed to Robert E. Robert at SENSEI@HOUSEOFKOKONDO.COM and understand there are no refunds after authorization has been completed. A copy of the authorization will be mailed to the address listed above. Signature:__________________________________ Date:_________________________