2016 Entrepreneurial Insurance Symposium EIS Brochure | Page 14

Sponsorship Opportunities SPONSORSHIP AGREEMENT & SELECTION FORM - PART II Sponsors may pay for both sponsorship and additional attendee registration ($420 value) via check or credit card. Please forward your payment immediately to avoid delay. Note: No one will be admitted to the event and exhibit hall without a badge. Method of Payment: American Express MasterCard Visa Check #_______________ Credit Card #: _________________________________ Exp. Date (MM/YY): ____________ CVC #: ___________ Credit Card Billing Address: _______________________________________________________________________ City: ________________________________________ State: ______________________ Zip: ____________________ Name on Card (Please Print): ______________________________________________________________________ Signature (Required): ____________________________________________ Date: ___________________________ Attendee Registration Information First Name: ________________________________________ Last Name: __________________________________ Badge Name (if different from above): _____________________________________________________________ Company Name: ___________________________________ Title/Position: ________________________________ Mailing Address: __________________________________________________________________________________ City: ________________________________________ State: ______________________ Zip: ____________________ Phone: ________________________________________ Fax: ______________________________________________ E-mail: ____________________________________________ Website URL: _________________________________ Attendee Registration Information First Name: ________________________________________ Last Name: __________________________________ Badge Name (if different from above): _____________________________________________________________ Company Name: ___________________________________ Title/Position: ________________________________ Mailing Address: _________________________________________________________________________________ City: ________________________________________ State: ______________________ Zip: ____________________ Phone: ________________________________________ Fax: ______________________________________________ E-mail: ____________________________________________ Website URL: _________________________________ Please send completed Sponsorship Agreement & Selection Forms Part I & II to Diahann Doyen by fax at [phone] or email at [email protected]. You will receive confirmation once your sponsorship has been approved. Sponsorships are assigned on a first-come, first-served basis and are non-refundable. Tel: [phone] Email: [email protected] www.eInsuranceSymposium.com