_SOCIETY OF TEACHERS OF FAMILY MEDICINE
APPLICATION FOR CONFERENCE SUPPORTER
2017 Family Medicine Midwest Conference
Hilton Rosemont Chicago O'Hare
October 6-8, 2017
Please enter your information as you would like it listed in the on-site program guide
Company Name:
Contact Person: __________________________________
Phone: Email:
City, State: ________________________________________________________________________________
Name of staff for booth (limit of 2):
_________________________________________________________________________________________
[pic]$5500 Platinum Level Supporter/Exhibitor
[pic]$2500 Gold Level Supporter/Exhibitor
[pic]$1500 Employer & Residency Fair Exhibitor Supporter (Saturday only)
[pic]$1000 Silver level Supporter
[pic]$500 Bronze Level Supporter
[pic]$100 Individual FMM Supporter
Electrical Access Addition - $100
Additional Recognition opportunities:
[pic]Advertisement in Onsite Program Book – Full or half-page four-color ad available
[pic] $750 full page AD [pic] $400 ½ page AD
[pic] Advertise on Continuous-looping Conference Slideshow – $500
[pic] Place brochure/flier in Attendee Welcome Bags – $500
[pic] Sponsor of Attendee Lounge Area - $500
TOTAL DUE $
P A Y M E N T
□ Check enclosed ~ payable to Family Medicine Midwest Foundation, Tax ID #46-1777069
□ Credit Card I hereby authorize use of my: □ Discover □ Visa □ MasterCard □ American Express
Card # Signature__________________________________________
Expiration Date CVC/CVV#: _____ ___ Total $ _________________
Complete this form and send payment to:
Family Medicine Midwest/IAFP, Attn: Desma Rozovics, 747 E Boughton Rd, Ste 253, Bolingbrook, IL 60440
Fax: (312) 604-0811 E-Mail: drozovics@
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