HWS & Whiplash Group

Please select your sponsorship

** Sponsorships are 1/2 OFF with the earlybird special.

Earlybird special is two parts. Paid in full more than 120 days in advance AND a promise to cross-promote the event to you contacts.

(Cross promotion promise is 2 to 3 promotions by mail, email, or phone blast)

Keynote or Speaker Sponsor	$5000
Continuing Education Sponsor (Docs love this!)	call
Meal Sponsor	call
Entertainment Sponsor (Friday night)	call
Name Badge Sponsor	call
Silver Sponsor or Booth Sponsor	$3000

Platinum Sponsor (1 year all events)	$5000
Platinum Sponsor (1 year all events) monthly payments	$450
Gold Sponsor (1 year all events)	$2500
Gold Sponsor (1 year all events) monthly payment	$225

Payment Information
Description	3 DAY Seminar Sponsorship
Payment Amount	Frequency When will monthly payments start? How long will payments go? How many monthly payments?

Contact
First Name*
Last Name*
Email*
Verify Email*
Number Of Staff/Team Members
Names of those attending

Billing Address
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

Check To Confirm

Please check the box to confirm you want to schedule Monthly Payments and not be charged at this time.

Enter /Your Full Name/
to Sign and Authorize.

*Required

I affirm that the information entered on this form is true and correct.

HWS & Whiplash Group
10462 S. Redwood Dr South Jordan, UT 84095
(801) 867-9714

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.