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_________________________________________________________________
(Calendar year recognition at meetings, webinars, and websites.
PAYMENT 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 |