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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: kptaky@gmail.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!

WWW.KPTA.ORG


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 kptaky@gmail.com


Kpta call for sponsors