2023 SPONSORSHIP FORM Annual SCJMHS Conference 41 st Annual South Central Joint Mine Health and Safety Conference on April 3 – 5, 2023 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 a brief description of services and / or products the company offers as soon as possible to post to our “2023 LIST OF SPONSORS" webpage- NOTE: 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.Sponsorship Levels are as follows:*Please select level for participant registration information: $5000 Diamond Level (Includes 5 paid participant registrations and company bio displayed on our website) $4000 Diamond Level (Includes 4 paid participant registrations and company bio displayed on our website) $3000 Platinum Level (Includes 3 paid participant registrations and company bio displayed on our website) $2000 Platinum Level (Includes 2 paid participant registrations and company bio displayed on our website) $1000 Gold Level (Includes 1 paid participant registration, and company bio displayed on our website) $500 Silver Level (Includes company name ONLY recognized in the printed program) $250 Bronze Level (Includes company name ONLY recognized in the printed program)$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.Total $0.00 Card Billing InformationCredit Card*Card Details Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Have questions? Contact Us