Exhibitor/Sponsor Application

Texas Hospital Association 2009 Leadership Conference

PAY ONLINE:
To submit the exhibitor/sponsor application and payment online, please complete the form below and click "Submit."

PAY BY CHECK:
Do not complete the online form below. Please download and complete this form instead and mail it to THA.

UPDATES / CHANGES TO FORM: Do not complete the online or printed forms again. Please e-mail your changes to registrar@tha.org or fax to 512/692-2653.

COMPANY INFORMATION * Required fields

Company Name:
(EXACTLY as you wish it to appear in conference printed materials)

Address:

City:

State:

ZIP:

Main Phone: Web Site: www.

Is your company THA Endorsed? Yes No

Is your company a THA Corporate Member? Yes No

CONTACT INFORMATION

Contact Information:

Contact Name:

Title:

Phone:

Fax:

E-mail:

EXHIBITOR / SPONSOR OPTIONS

Note: Selection does not guarantee availability. All exhibit/sponsor opportunities are offered on a first-come, first-served basis.

Exhibitor Option	$ ($5,000 or $3,000 levels)
Sponsor Option	$ (See fees below)

Select desired sponsor event(s):

General Session #1 ($5,000)	HOSPAC Reception ($5,000)	Buses ($5,000)
General Session #2 ($5,000)	ACHE Breakfast ($3,000)	THT Architecture/Construction Exhibit Display and Reception ($1,500)
Breakout Session #1 ($3,000)	Continental Breakfast ($2,500)	Hotel Room Key ($5,000)
Breakout Session #2 ($3,000)	Refreshment Break #1 ($2,500)	Conference Notebook ($5,000)
Welcome Reception ($5,000)	Refreshment Break #2 ($2,500)	Pen ($5,000)
Awards Lunch ($5,000)	Refreshment Break #3 ($2,500)
Town Hall Lunch ($5,000)	Registration Area ($5,000)

PAYMENT

Charge payment to:
I authorize THA to charge

$ to my:

MasterCard Visa American Express
                                                  Note: Do not include commas in payment amount. Use $12500, not $12,500.

Account Number:

Expiration Date: /

Cardholder First Name:

Cardholder Last Name:

Billing Address:

City:

State:

ZIP:

REGISTRANTS

Complimentary Representative #1
Name:
Title:
Phone:
E-mail: City: State: ZIP:

Select events that Representative #1 will attend:
THA Town Hall Lunch (noon Jan. 21 ) ACHE Breakfast (7 a.m. Jan. 22) THA Awards Lunch (11:15 a.m. Jan. 22)

Complimentary Representative #2
Name:
Title:
Phone:
E-mail: City: State: ZIP:

Select events that Representative #2 will attend:
THA Town Hall Lunch (noon Jan. 21 ) ACHE Breakfast (7 a.m. Jan. 22) THA Awards Lunch (11:15 a.m. Jan. 22)

Complimentary Representative #3 - $5,000 level only
Name:
Title:
Phone:
E-mail: City: State: ZIP:

Select events that Representative #3 will attend:
THA Town Hall Lunch (noon Jan. 21 ) ACHE Breakfast (7 a.m. Jan. 22) THA Awards Lunch (11:15 a.m. Jan. 22)

Complimentary Representative #4 - $5,000 level only
Name:
Title:
Phone:
E-mail: City: State: ZIP:

Select events that Representative #4 will attend:
THA Town Hall Lunch (noon Jan. 21 ) ACHE Breakfast (7 a.m. Jan. 22) THA Awards Lunch (11:15 a.m. Jan. 22)

Executive Invitation to THA Board Dinner - 7:30 p.m. Jan. 20 ($5,000 Exhibitor level only)
Name:
Title:
Phone:
E-mail: City: State: ZIP:

...