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:*
MSHA ID#
Company Address*
Street Address Address Line 2 City 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)
Participant #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) Statement
The 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*
Please select level that matched your requested level above for payment.
Card Billing Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Total
$0.00

2019 SPONSORSHIP FORM

37th Annual SCJMHS Conference

IRS Code Section 501(c)(3) Statement

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