HFMA Hudson Valley NY Chapter
2019 Annual Institute Sponsorship Registration Form
Registration is a Guarantee of Payment
I would like to sponsor the 2019 Annual Institute for the level indicated below:
( Morning Keynote - $4,250 ( Afternoon Keynote - $4,000 ( Reception - $3,650
( Luncheon - $2,850 ( Breakfast - $2,850
( Exhibitor II - $2,250 ( Exhibitor I - $2,000 ( Education - $1,000
Name of Organization: __________________________________________________
(exactly as you wish it to appear in all printed materials)
Address of Organization:
Address 1: ____________________________________________________
Address 2: ____________________________________________________
City, State, Zip: ____________________________________________________
Primary Business Contact (to be included in printed materials):
Name & Title:__________________________________________________________
Telephone Number:____________________ Fax Number: _____________________
E-Mail Address: ________________________________________________________
Primary Administrative Contact (if different from Business Contact):
Name & Title:__________________________________________________________
Telephone Number:____________________ Fax Number: _____________________
E-Mail Address: _______________________________________________________
FAX this form to: Christy Spencer, Sponsorship Chair at (914) 418-1042
Check payable to: Healthcare Financial Management Association
And mail check to: Perry Santullo, Treasurer
629 Fifth Avenue, Suite 221
Pelham, NY 10803
PAYMENT IS DUE NO LATER THAN March 22, 2019
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