2024 SPONSORSHIP FORM Annual SCJMHS Conference 41 st Annual South Central Joint Mine Health and Safety Conference on March 25-27, 2024 Company Name:* Company Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 “2024 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 Black 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 Plus 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 Black Diamond Level$4000 Diamond Level$3000 Platinum Plus 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. DISCLAIMER: By Registering for the conference, you understand photographs will be taken and used on our website. All Company and personal information will be protection. WE DO NOT SHARE ANY LIST OF PARTICIPANTS. Thank you for your support!!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 NameThis field is for validation purposes and should be left unchanged. Have questions? Contact Us