MSHP 2021 Virtual Annual Conference Executive …



2895603810MSHP 2021 Virtual Annual Conference Executive NetworkingVendor Registration FormThursday, April 22, 20212:35 – 4:35 PM00MSHP 2021 Virtual Annual Conference Executive NetworkingVendor Registration FormThursday, April 22, 20212:35 – 4:35 PMExecutive Networking Program Features:This format creates a more relevant, efficient, cost-effective venue to meet more Health System decision makers! Participant profiles will ensure vendors meet with participants that share a clinical interest From 2:35 – 4:35 PM vendors will meet with individuals. A schedule will be provided prior to the meeting.Vendor Information: Contact Name: FORMTEXT ?????Email: FORMTEXT ?????Job Title: FORMTEXT ?????Telephone: FORMTEXT ?????Company Name: FORMTEXT ?????Address: FORMTEXT ?????Website: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Participant Information: Representatives that will attend the Executive Networking event (up to 3 representatives can attend).Name: FORMTEXT ????? Job Title: FORMTEXT ?????Email: FORMTEXT ????? Participant Profile (will be shared with health systems):Education: FORMTEXT ?????Current Work Responsibilities: FORMTEXT ????? Clinical Areas of Interest: FORMTEXT ?????A fun fact about you: FORMTEXT ?????Name: FORMTEXT ????? Job Title: FORMTEXT ?????Email: FORMTEXT ?????Participant Profile (will be shared with health systems):Education: FORMTEXT ?????Current Work Responsibilities: FORMTEXT ????? Clinical Areas of Interest: FORMTEXT ?????A fun fact about you: FORMTEXT ?????Name: FORMTEXT ????? Job Title: FORMTEXT ?????Email: FORMTEXT ?????Participant Profile (will be shared with health systems):Education: FORMTEXT ?????Current Work Responsibilities: FORMTEXT ????? Clinical Areas of Interest: FORMTEXT ?????A fun fact about you: FORMTEXT ?????Participation Options: FORMTEXT ????? Corporate Business Partners (CBP): We wish to participate in the Executive Networking event at MSHP’s 2021 Virtual Annual Conference. We are signed up as the following CBP: FORMTEXT ????? Platinum Plus FORMTEXT ????? Gold Plus FORMTEXT ????? Silver Plus (There is no charge as a CBP at one of the Plus Levels to participate at the Executive Networking.) FORMTEXT ????? Annual Conference Exhibitor: We wish to participate in the Executive Networking event at MSHP’s 2021 Annual Conference. Exhibitor Bundle Package (includes Exhibitor Fee and Executive Networking Fee: $2,000 Note: Executive Networking participants are required to sign up to exhibit at the Virtual Annual Conference. Application will be confirmed after submission.Payment Options (circle one): CHECK VISA MASTERCARDAMERICAN EXPRESSPlease make checks payable to MSHP and forward payment and application to MSHP office: 13911 Ridgedale Drive, Suite 260, Minnetonka, MN 55305. MSHP Tax ID #: 41-1401022Name on Card: FORMTEXT ?????Billing Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Credit Card #: FORMTEXT ????? CVV#: FORMTEXT ?????Expiration Date: FORMTEXT ?????Signature: FORMTEXT ????? Date: FORMTEXT ?????Confidentiality Notice: All cardholder data is maintained exclusively for the use of our customers in the authorization, settlement, archiving and retrieval of credit card information in the course of business. Due to PCI Compliance, please do not provide any credit card information via email. Instead, you can call MSHP office at 952-541-9499 or fax the form to 952-541-9684.We agree to comply with all the Rules and Regulations connected with participation in MSHP activities as outlined. FORMTEXT ????? FORMTEXT ?????SignatureDateSubmit completed form to mpeterson@ or fax to 952-541-9684 ................
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