Sponsor / Exhibitor Application

Personal Information
Company Name*
Company Representative Name*
First Last
Title
Phone*
Email*
Second Company Representative Name*
First Last
Title
Second Company Representative Email*
Business Website
Business Description*
Company Logo
Max. file size: 32 MB.
Please provide an official company logo to be used on our website, convention app, and social media platforms.
Type of Sponsorship
Which level of Sponsorship are you interested in?*
- Harvey Lillard Banquet - $15000
- Platinum Level - $4000
- Gold Level - $3000
- Silver Level - $2000
- Bronze Level - $1000
- Exhibitor - $400
Harvey Lillard Banquet Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Dr. Bobby Westbrooks Luncheon Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Welcome Reception Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Friday Night Social Event Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Doctor's Roundtable Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Continuing Education Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Platinum Level Sponsor
Price:
Along with your sponsorship of $4,000 or more, you will be given free exhibitor table in designated area.
Gold Level Sponsor
Price:
Silver Level Sponsor
Price:
Bronze Level Sponsor
Price:
Exhibitor Table Quantity
Price: $400.00
Payment Information: Important
Please Note: The credit card billing address must match the address on file with the bank. If the addresses do not match, the transaction will be declined.
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please Note: The credit card billing address must match the address on file with the bank. If the addresses do not match, the transaction will be declined.

Sponsor / Exhibitor Application

Personal Information

Type of Sponsorship

Payment Information: Important