Exhibitor - Sponsor Registration Form

Digital Marketing Track Biomechanics Track Quality of Care Track Faculty Venue / Hotel About the Meeting Doctor Registration Exhibitor Registration

Presents the Long Island Practice Summit
March 3, 2019 | Wang Center – Stony Brook University, Stony Brook NY

We have a limited number of tables and sponsorships. To ensure you are represented at the meeting we recommend that you register and pay online.
Please download the Exhibitor Terms Document. It has all of the rules and regulations associated with agreeing to be a sponsor or exhibitor
To pay by Credit Card and reserve your space CLICK HERE

Exhibitor Sponsor Form
Company Name_________________________________ Main Contact ___________________________________
Contact Email ___________________________________ Phone _________________________________________
Address _______________________________________ Fax ___________________________________________
City ___________________________________________ Web Address http://_____________________________

State __________________________________________ Email Address __________________________________
Representative 1
Name _________________________________________ Badge Name ___________________________________
Cell Number ____________________________________ Email Address __________________________________
Representative 2
Name _________________________________________ Badge Name ___________________________________
Cell Number ____________________________________ Email Address __________________________________

Fees
Exhibitor Registration includes registration for 2 representatives, display table, Electricity at display table and post conference attendee list
Exhibitor Tables (50% discount for speaker sponsors) Fee
☐ Exhibitor (before December 1, 2018) $800
☐ Received after Dec 1 but before Feb 1, 2019 $1,000
☐ Received after Feb 1, 2019 $1,200

Speaker Sponsorships
☐ Non CECH Speaker Sponsor
Includes
recognition that you sponsored the speaker
you provide the speaker for the program.
☐ $1,200 to sponsor 1 speaker
☐ $1,800 to sponsor 2 speakers

☐ CECH Speaker Sponsor
Includes
recognition that you sponsored the speaker.
As per CPME regulations we contract with all speakers.
$2,000

☐ Continental Breakfast $1,000
☐ Morning Coffee Break $1,000

☐ Lunch
Includes
link on conference web site,
pre conference attendance list,
signage at lunch
recognition in conference documents.
$2,500

☐ Afternoon Coffee Break $1,000

☐Platinum Sponsorship (1 available)
Includes
link on conference web site,
pre conference attendance list,
signage at conference and recognition in conference documents
2 tables in exhibit area.
The ability to provide bags and name tag lanyards for every attendee.
$4000

☐Gold Sponsorship (3 available)
Includes
link on conference web site,
signage at conference and recognition in conference documents
1 table in exhibit area.
1 insert in the attendee bag.
$2,000

Total
Payment Type: ☐ Check ☐ Visa ☐ Mastercard ☐ American Express
Name on Card ___________________________________ Card # _________________________________________
Billing Address __________________________________ Expiration Date __________________________________
Billing City ______________________________________ CVV ___________________________________________
Billing Zip ______________________________________ Total __________________________________________
Signature _______________________________________ Date __________________________________________

Please return form to CME Online P. O. Box 674 Southold, NY 11971 or fax to (631) 547 1423