GEORGIA MEDICAL DIRECTORS ASSOCIATION

                        WEBINAR / PROGRAM / EXHIBIT PAYMENT INFORMATION

This is the information for all sponsorships and exhibits. We will be happy to provide a letter of solicitation or application per your requirements and a W-9 form. This is not a fillable form at this time. Please call 404-401-0225 to provide information and answer questions.

WEBINAR OR SYMPOSIUM NAME:__Georgia Medical Directors Association 2021 Winter Virtual Symposium___

WEBINAR OR SYMPOSIUM DATE:___January 23, 2021_________________________________________

INDUSTRY  PARTNER____________________________________________________________________

REPRESENTATIVE NAME_________________________________________________________________

• INDUSTRY PARTNER WEBINAR FEE                                             ___$300 (1/2 hr presentation)    ___$  600 (1 presentation)

• EXHIBIT (face-to-face)                                                                      ___$  950

• EXHIBIT PRESENTATION (Webinar Meeting)                                 ___$  500

• ANNUAL ASSOCIATION SPONSORSHIP:

        (Calendar year recognition at meetings, webinars, and websites.

• Platinum                                                                                          ____$3500
• Gold                                                                                                 ____$2500
• Silver                                                                                               ____$1500

PAYMENT INFORMATION

• Check Enclosed
• Check will come from company
• Credit Card Information

Card Type:  ___VISA ___M/C ___AMEX ___DISCOVER

Card Number: ______________________________________________________________________

Expiration Date:____________    CV/CC Number (3 or 4 digit)_________________________________

Name on Card: ______________________________________________________________________

Billing Address:______________________________________________________________________ 

City / State / Zip: _____________________________________________________________________ 

Telephone: ________________________Email:____________________________________________

Payment receipt will be automatically sent to your email