IM4US 2019 Conference Sponsor/Exhibitor Application
Email address *
Sponsor Information
Official Sponsor Name *
Company/Organization name or first and last name if individual as it should appear on marketing materials
Organization Type *
*Commercial Interest (corporations only)
Is your corporation a commercial interest? A commercial interest is any entity producing, marketing, reselling, or distributing health care products consumed by or used on patients, such as pharmaceuticals, supplements, medical devices, etc.
Sponsor Address *
Street Address, City, State, Zip
Sponsor Website
Enter the company or personal website of the sponsor.
Sponsor Description *
Mission Alignment *
Sponsor Logo (High Resolution)
Please upload a high-resolution, print-quality logo.
Sponsor & Exhibitor Interest
I am interested in... *
Sponsor Level Desired *
Please tell us what sponsorship package you're applying for.
Exhibitor Table Desired
Please tell us which exhibitor level you're applying for.
Please provide details about your sponsor or exhibitor interest, if needed.
Exhibitor Name & Phone (if applicable)
If exhibiting, enter the name and cell phone number of the person who will be tabling at the conference, if known.
Representative Contact Information
Person who will be the point of contact leading up to the conference.
Representative Name *
Representative Title *
Representative Organization *
Representative Email *
Representative Phone *
Billing Information
Enter the billing information as it should appear on invoice
Billing Contact *
Full name of the billing contact for this sponsorship
Billing Company Name *
Billing Address *
Billing Email *
Billing Phone *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service