10th Annual Conference Sponsor Form

Contact Name *

Company *

Copy of your logo in JPG format

No file chosen

Email *

Phone

Twitter

Facebook

Select Your Level of supportConference Title Sponsor ($25000)Tuesday Key Note Sponsor ($15000)Opening Night Reception Sponsor ($10000)Gold Level Sponsor ($5000)Silver Level Sponsor ($2500)Bronze Level Sponsor ($1500)Featured Exhibitor ($1000)Exhibitor ($500)

Fee ($)

Are you approved to send a check? We will contact you with more details once you submit the application *YesI will pay by credit card

Billing Address

City

State

ZIP Code

Country

Credit Card *

Credit Card Authorization *

YesI authorize the Alcohol & Drug Abuse Certification Board of Georgia (ADACBGA) to charge my credit card above for the agreed upon purchase. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Date