EmailMe Form - 2012 Exhibitor, Sponsor & Advertiser Application

Organization *

Name of Primary Representative *

Contact Email *

This will be the email address NCHN uses to correspond with you about the Conference.

Phone Number *

### - ### - ####

Fax Number

### - ### - ####

Website

Mailing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

My organization is submitting this application to (check all that apply): *

Exhibit

Sponsor

Advertise in the Conference Program

Exhibitors

Select your Exhibitor Category below.

In addition to the Exhibit fee, each booth representative must pay the reduced registration fee ($350/ea.) to cover costs of meals during the conference.

Exhibitor Level *

Non-NCHN Affiliated For-Profit Business: $800

Non-NCHN Affiliated Non-Profit Business: $500

NCHN Member Business Partner: Free

NCHN Gold Business Partner: Free

NCHN Silver Business Partner: $250

Booth Representative 1:

First Last

Booth Representative 2:

First Last

Booth Representative 3:

First Last

I prefer a booth next to [name of organization]:

Optional: Please let us know if you prefer to have your booth located next to or near a specific organization.

Will you be attending the NCHN Opening Reception on Sunday? *

I/We will attend the Opening Reception Sunday evening

I/We will NOT attend the Opening Reception Sunday evening

Number of Guest Tickets for Sunday Night Reception ($55/guest):

Enter the # of tickets for guests of Booth Representatives. Enter 0 if you will not be bringing guests to the reception.

Will you be attending the Rockies Baseball Game and dinner on Monday night?

I/We will attend the Rockies Baseball Game and dinner

I/We will NOT attend the Rockies Baseball Game and dinner

Number of Guest Tickets for Monday Night Rockies Baseball Game ($85/guest):

Enter the # of tickets for guests of Booth Representatives. Enter 0 if you will not be bringing guests.

Name/s of Guests

If any booth representatives will be bringing a guest to the opening reception or Monday night baseball game, please enter the guest name/s.

Advertisers

Advertising opportunities are available in the 18th Annual Educational Conference Program. Art work must be high-resolution (300 dpi jpg,pdf, ai, psd) and emailed to csullenberger@nchn.org no later than March 15, 2012.

Conference Program Advertisement (Full Color): *

Full Page: $800

Half (1/2) Page: $450

Quarter (1/4) Page: $250

Business Card (3.25" x 1.75"): $125

Information for the Website and Conference Program

All opportunities include logo and acknowledgement in the Conference program and Conference Web site

Description of your Organization/Service (as you would like to have it listed on the Conference Website and Program): *

NCHN reserves the option to edit your description if it exceeds available space on the website or conference program (Recommended: 250 words or less).

Optional: Upload your organization's logo (1 MB max)

NOTE: If you do not upload a logo, please email a high resolution (300dpi) copy to csullenberger@nchn.org by March 5, 2012 to have it displayed in the appropriate locations

Payment

Check must be received before NCHN can consider your application. Mail payment by March 1, 2012 to:

NCHN (National Cooperative of Health Networks Association)
c/o Rebecca J. Davis
624 South 1st Street
Montrose, CO 81401

a. Exhibitor/Sponsor/Advertiser Amount=

b. Registration Fee for Booth Representatives ($350 x Number of Representatives)=

REQUIRED: Booth representatives must register for the conference to cover meal costs. The conference registration fee covers the Opening Reception on Sunday night, and meals and breaks on Monday and Tuesday.

c. Sunday Night Reception Guest Tickets ($55 x Number of Guests)=

d. Monday Evening Networking Event Tickets ($85 x Number of Guests)=

Total Amount (a+b+c+d)=

Check Number

Billing Address (if different from address above)

Street Address City State / Province / Region Postal / Zip Code Country / Region

Note: By providing your contact information, you authorize the National Cooperative of Health Networks to communicate with you regarding event information and to process your registration.

Terms & Cancellation

Note: Full payment must accompany an application for Exhibit space or Sponsorship. Payments must be sent by mail to NCHN, 624 South 1st Street,
Montrose, CO 81401. Booth assignment will not be made without receipt of payment. Cancellation of exhibit space or sponsorship must be received by the National Cooperative of Health Networks prior to April 1, 2012, to receive a refund (minus a $50 administrative fee).

By providing your contact information, you authorize the National Cooperative of Health Networks to communicate with you regarding event information and to process your registration.

After submitting your application, you will be redirected to the Sponsor Planning page. If you have any questions about this form or planning, contact Christy Sullenberger at 540-352-2529 or csullenberger@nchn.org

Terms & Cancellation *

I have read and understand the terms and the cancellation policy above.

Comments