2014 Annual Conference Call for Sponsors LEVEL 1 ($400) LEVEL 2 ($350) LEVEL 3 ($250) Company Name: ____________________________ Contact Name: ____________________________ E-mail: ____________________________ Phone: ____________________________ Submit with payment to KPTA 15847 Teal Road, Verona, KY 41092. To pay by credit card, complete & submit the form on the reverse page.
Join us as a sponsor at our 2014 Annual Conference. Sponsors are invited to set up a display at our “Celebration of You” member reception and awards gala being held on September 26 from 7:00pm10:00pm at the Barrel House (903 Manchester Street, Lexington). Space is limited and sponsors will be accepted on a first come-first served basis. Level 1 sponsors receive: Exhibit table at the reception Full-page ad in the KPTA Newsletter
15847 Teal Road, Verona, KY 41092 Phone/Fax: 859.485.2812 Email: email@example.com
One time use of KPTA member mailing list Level 2 sponsors receive: Exhibit table at the reception One time use of KPTA member mailing list Level 3 sponsors receive: Exhibit table at the reception Please select your level at left and reserve your spot today!
CREDIT CARD CHARGE AUTHORIZATION Name on card: __________________________________________________________________ Billing address:__________________________________________________________________ City/state/zip:____________________________________________________________________ Card number:___________________________________________________________________ Exp. Date:____________________________________Security Code:______________________ Signature:______________________________________________________________________ Please select your level: LEVEL 1 ($400) LEVEL 2 ($350) LEVEL 3 ($250)
Submission of this form indicates your agreement for the Kentucky Physical Therapy Association to charge your American Express/Mastercard/Visa for the amount selected above. Questions? Contact KPTA at 859-485-2812 15847 Teal Road Verona, KY 41092 firstname.lastname@example.org