2006
CONVENTION
SPONSOR

YES, we want to be a sponsor
  of Ohio's 6th PHCC/ACCA Convention

o Metal Sponsor  = ____ Platinum ($1,500) ____ Gold ($1,000)  ____ Silver ($500)

  ____ Bronze ($250)      ____ Friend (any amount up to $250)

o Special Event  =  Special Event ____________________ Amount $___________

Company Name____________________________________________________________

Representative_____________________________________________________________

Signature__________________________________________________________________

Address___________________________________________________________________

City/State/Zip_______________________________________________________________

Phone (_____)__________________________Fax (_____) _________________________

Email _____________________________________________________________________

o Logo for use on Sponsor Recognition Sign   (Please send by February 1)

o Sent to conventionacphc@aol.com (please use jpeg or tif)
o Enclosed 

o Check enclosed 

o Please send invoice (must be paid before February 15, 2006)

o CREDIT CARD CHARGE:  

o Visa    o MasterCard     o Discover       Amount $_____________________

Credit card number: ________________________________________________________
Exp. Date:__________________________________________

Name on Card (print) _______________________________________________________
Signature__________________________________________________________________

Return to: 2006 Ohio ACCA – PHCC Convention
18961 River's Edge Drive, Chagrin Falls, OH 44023

Thank you for your support!