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North Carolina Providers Council
Exhibit/Sponsorship Registration Form
October 6-7 2009
Accepting the Leadership Challenge ….
Sponsorship Opportunities: Check all that apply
____ 5-Star Sponsor Level for $2,750 (limit 5)
Includes 1 year Provider Support Membership Dues*
____ 4-Star Sponsor Level for $2,250
Includes 1 year Provider Support Membership Dues*
____ 3-Star Sponsor Level for $1,000
____ 2-Star Sponsor Level for $750
____ 1-Star Sponsor Level for $500
____ I wish to exhibit as a Non-member for $425
____ I wish to exhibit as a member for $325
____ I will need electricity and have included an additional $40
____ *I have included my Provider Support membership application with my sponsorship package
Payment Options: [ ]Check/Cash [ ] MasterCard/Visa [ ] Discover
Cardholders Name: ______________________________________________Amount:___________________
Card #: ________________________________________________________**Exp. Date:________________ Billing Address w/zip code of card:____________________________________________________________
Check #: _______________________Amount:_________________________
(Make check payable to NC Providers Council)
EASY ways to reserve your space:
aRegister on-line via our website
aCall 919-784-0230
aFax with Credit Card to 919-784-0231
aEmail PDF of form using a credit card
to: diana.mills@ncproviderscouncil.org
aMail: NC Providers Council
Attn: Diana Mills
4700 Homewood Court, Ste. 320
Raleigh, NC 27609
Sheraton Greensboro at Four Seasons
2009 Annual Conference
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