Sponsorship and Supporter Form

* Indicates required field

Company Name *

Contact Name *

Address *

City *

State *

Zip *

Phone *

Fax

Contact Email *

Website Address

Sponsorship Level (please select one)

Corporate Platinum Sponsor: $3,000

Exclusive Lunch Sponsor: $2,000

Exclusive Coffee Sponsor: $2,000

Silver Sponsor (industry exclusivity): $1,500

Gold Sponsor: $2,500

Bronze Sponsor: $500

No thanks

Supporter Opportunities (please select one)

Corporate Table Sponsor (8 seats): $1,500.00

Student Individual Early Registration Fee: $169.00

No thanks

Company description

Please provide a three to four sentence description of your company.

Sponsorship commitment form and company information must be received by January 1, 2017 to be on the website when registration opens, and by January 15, 2017 to be recognized in printed participant materials. When payment is received, you will be receive the Sponsorship/Supporter contract with details regarding your exhibit space.

If you have additional information about being a sponsor or a supporter, please contact Louise Korver at louisek@gxdllc.com.

Please enter your Contact Information

Is this gift on behalf of an organization? * Yes No
Organization Name *
First Name *	Last Name *
Email *	Phone * Mobile Home Work Opt-in to receive account, event, and important notices via text message. Msg & Data rates may apply. To opt-out reply STOP at any time.

Address *
Country *
City *	State/Province *	Zip/Postal *

Please enter your Billing Information

We accept the following cards
Name on Card *	Card Number *
Expiration Date *	Security Code(CVV) * ?

Use same address as Contact Information
Billing Address *
Country *
City *	State/Province *	Zip/Postal *

$0.00