Sponsorship & Exhibits Payment Form MME | Exhibitor Payment Form Select the conference from the pull down. * September 25-26, 2020 – Breast Cancer Symposium October 10, 2020 – Spring to Life November 6-7, 2020 - Long Island Heart If you are paying for more than one conference, please submit the payments separately. Exhibiting Company Name: Exhibiting Company Name: * Exhibiting Company Contact: Exhibiting Company Contact First Name * Exhibiting Company Contact Last Name * Exhibiting Company Contact Email * Exhibiting Company Contact Phone * Virtual Trade Show Booth Coordinator: Virtual Trade show Booth Coordinator First Name * Virtual Trade show Booth Coordinator Last Name * Virtual Trade show Booth Coordinator Email * Virtual Trade show Booth Coordinator Phone * Virtual Trade Show Booth Participant 1: Virtual Trade show Booth Participant First Name * Virtual Trade show Booth Participant Last Name * Virtual Trade show Booth Participant Title Virtual Trade show Booth Participant Email * Virtual Trade show Booth Participant Phone * Virtual Trade Show Booth Participant 2: Virtual Trade show Booth Participant 2 First Name Virtual Trade show Booth Participant 2 Last Name Virtual Trade show Booth Participant 2 Title Virtual Trade show Booth Participant 2 Email Virtual Trade show Booth Participant 2 Phone Sponsorship Selections Sponsorship Selections Bronze = $2,500 Silver = $3,750 Gold = $5,000 Product Theater = $10,000 Sponsorship Selections Bronze = $5,000 Silver = $6,750 Gold = $7,500 Product Theater = $10,000 - Product Theater sessions are being assigned on a first-come, first-served basis- Company must be exhibiting in order to be considered for a Product Theater sessionIf you are interested in a Product Theater session, please email nicole@mymededco.com to discuss availability before you complete the application. Billing Information Please Select * Pay Via Check Pay Via ACH/Wire Transfer Pay Via Credit Card Already Paid Make Checks Payable to: myMedEd, Inc. 518 S. IL Route 31 #194 McHenry, IL 60050 TAX ID: 82-4893155 First Name - Billing * (Name on card) Last Name - Billing * (Name on card) Payment Amount * Purchase Notes * Address - Billing * Address - Billing Address - Billing Address - Billing Address - Billing Address - Billing State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address - Billing Credit Card - Billing * If you are human, leave this field blank. Submit Application
