Become A Conference Sponsor Thank you for assisting us with the funding of this educational opportunity for our Members. Sponsorship Commitment Form Please complete all sections of the form below with payment by Wednesday, August 21, 2019.Section 1 - Contact InformationCompany Name:* Contact's Name:* Mailing Address:* Street Address 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 Phone:*Fax:Contact's Email:* Contact's Signature:*Section 2 - Sponsorship LevelSponsorship Benefits: Gold Sponsorship a. Two complimentary conference registrations b. Recognition as a Gold Sponsor at the Conference General Session c. Recognition in the conference program book Silver Sponsorship a. One complimentary conference registration b. Recognition as a Silver Sponsor at the Conference General Session c. Recognition in the conference program book Bronze Sponsorship a. Recognition as a Bronze Sponsor at the Conference General Session b. Recognition in conference program book Choose a Sponsorship Level:* Gold $1,500 Silver $1,000 Bronze $500 Voluntary Additional Sponsorship Amount: Calculated Total: $0.00 Section 3 - Complimentary Registration InformationPlease select one of the following: Yes, we will be attending and taking advantage of the complimentary registration(s) as outlined in our level of participation. No, we will not be attending. Name of Registrant #1:* (Please enter the name and title as it should appear on your conference badge.)Name of Registrant #2: (Please enter the name and title as it should appear on your conference badge.)Section 4 - PaymentPayment Method* Credit Card Check Payment instructions: You will be directed to PayPal for credit card paymentWe welcome payment by check. If paying by check, simply close the PayPal window/tab of your browser after submitting the form. You will receive a copy of your commitment form by email containing detailed payment instructions. Please include the confirmation email with your check.Make checks payable to: PennPRIME Attn: Cheryl Lees414 North Second Street Harrisburg, PA 17101Need Assistance?For assistance, please contact:Cheryl Lees, Manager of Loss Control ServicesPhone: (717) 979-4221Email: clees@pml.org Δ Back to Conference Section
