2019 SPONSORSHIP FORM 37th Annual SCJMHS Conference 37th South Central Joint Mine Health & Safety Conference April 15-18, 2019~ The Hilton Anatole ~ Dallas, Texas Company Name:*Company Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Person (Point of Contact):* First Last Email* Phone*Company Description and Services*Please provide information that can be used on the Sponsor Page of the website, or information as to where this can be found. Your company website or web information listing we can use for information. Sponsorship Levels are as follows:*Please select level for participant registration information: $5000 Diamond Level (Includes 5 paid participant registrations, program ad, and company page on our website) $4000 Diamond Level (Includes 4 paid participant registrations, program ad and company page on our website) $3000 Platinum Level (Includes 3 paid participant registrations, program ad and company page on our website) $2000 Platinum Level (Includes 2 paid participant registrations, program ad, and company page on our website) $1000 Gold Level (Includes 1 paid participant registration, program ad, and company page on our website) $500 Silver Level(Includes company name ONLY recognized in program and on our website) $250 Bronze Level (Includes company name ONLY recognized in program and on our website)$5000 Diamond Level$4000 Diamond Level$3000 Platinum Level$2000 Platinum Level$1000 Gold Level$500 Silver Level$250 Bronze LevelParticipant #1 First Last Participant #2 First Last Participant #3 First Last Participant #4 First Last Participant #5 First Last IRS Code Section 501(c)(3) StatementThe SCJMHSC Association is legally established under the laws of Texas as a non-profit organization, donations to help fund it are tax-exempt under IRS Code Section 501(c)(3). Each sponsoring organization or individual will receive a copy (if requested) of the Conference Association’s IRS Form W-9 for tax reporting (charitable donation deduction) purposes.Select Level For Payment*Diamond Level $5,000.00Diamond Level $4,000.00Platinum Level $3,000.00Platinum Level $2,000.00Gold Level $1,000.00Silver Level $500.00Bronze Level $250.00Please select level that matched your requested level above for payment.Card Billing InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total $0.00 Have questions? Contact Us