Company Name:

Description of Product/Service:

Address:

City: ST Zip:

Phone: Fax:

E-Mail:

Exhibitor Contact

Booth Representative 1:

Booth Representative 2:

SPONSORSHIP

BENEFITS OF SPONSORSHIP

• Listing as sponsor by category on the AKOA website with a link to your company's website
• Listing as sponsor by category in the Onsite Manual
• Signage throughout the meeting facility
• Announcement at beginning of sponsored event

PAYMENT PROCESSING

Total Enclosed $

Credit Card Number ____________________________________

Cardholder's Name _____________________________________

Address (as shown on credit card statement) ______________________________________

Signature ______________________________________ Date: ____________

SUBMITTING FORM

1. Fill in the appropriate blanks.

2. Print Form

3. Complete Payment Processing Section

4. Mail or Fax to:

Alaska Optometric Association
1501 W 36th Ave, Ste 230
Anchorage, AK 99503
Fax: (907) 272 7532