PENNSYLVANIA ’ S DENTAL MEETING
SPONSOR APPLICATION / CONTRACT
Please complete all sections of this contract and print as clearly as possible so we can translate the information accurately . In submitting this application , you agree that you have read , understand and will abide by all of the rules and regulations outlined in the prospectus .
Please select from the following list to support Pennsylvania ’ s Dental Meeting 2024 :
Exhibit space |
($ 800 per table ) |
DIAMOND |
$ 10,000 & up |
RUBY |
$ 5,000 |
EMERALD |
$ 3,000 |
SAPPHIRE |
$ 1,500 |
Contributors any amount |
$ _____________ |
Co-sponsor a CE Speaker |
$ 1,500 |
Welcome Reception on 4 / 19 |
$ 2,000 |
Coffee Break |
$ 1,500 |
Lanyards for meeting attendees Donation |
Meeting Tote Bags |
Donation |
PLEASE PRINT
Company Name and Mailing Address
Describe Company Products / Services Contact Person & Title Email Address
Phone Number Authorized Signature ( individual who has authority to enter into contracts on behalf of the company ) Exhibitor Kit Should Be Sent To :
Full Name Subtotal $
Email Address
Total Due $ Today ’ s Deposit ( 50 % of Total Due ): $
PAYMENT ( MUST BE MADE IN U . S . FUNDS DRAWN ON A U . S . BANK )
� Check made payable to PDA is enclosed .
� Charge the credit card provided . � Mastercard � VISA � American Express � Discover
Card Number
Print the Name as it appears on the card
Expiration Date
Credit Card Billing Address Email the receipt to
If you are paying the deposit with a credit card , please indicate if you would like PDA to automatically charge the remaining balance .
� Please charge the remaining balance on March 29 , 2024 . � We will send a check to pay the balance ( must be received no later than March 29 , 2024 .)
Please complete and return to Rebecca Von Nieda by March 25 , 2024 : PDA , PO Box 3341 , Harrisburg , PA 17105 or fax ( 717 ) 232-7169 or rvn @ padental . org