Sponsorship Form

ICOPHAI 2013 SPONSORSHIP FORM

Name:_________________________________________________ Title:__________________________________

Agency/Comapny:_______________________________________Address:________________________________

City:____________ State: _________Zip/Postal Code:__________ Country________________________________

Email: __________________________________ Phone: _______________________Fax:____________________

Please select sponsorship type: (Descriptions of functions can be found in the attached info.)

™       Platinum Sponsor – US $10,000 and above

™         General sponsor at US $__________________________________________________________________

™         Specific function (Please indicate function)___________________________________________________

™       Gold Sponsor – US $5,000 to $9,999

™          General sponsor at $_____________________________________________________________________

™          Specific function (Please indicate function)___________________________________________________

™       Silver Sponsor – US $1,000 - $4,999

™         General sponsor at $_____________________________________________________________________

™         Specific function (Please indicate function)___________________________________________________

™       Other Sponsorship (in kind)

Please specify and special event/item:________________________________________________________

 

Checks and Credit Cards Accepted                                                  

                                                                                                   Credit Card Payments:

Make checks payable to:            Local Bank Transfer                  Card Type:

The Ohio State University          Banco do Brasil                         ™  Visa     ™ Mater card         ™ Amer. Express

College of Veterinary Medicine     Branch: 1591-1                           Print name:__________________________

1920 Coffey Rd                            Account #:  23.718-3                  Signature:___________________________

Columbus, OH 43210                  Beneficiary: ATECEL/ICOPHAI       Number:____________________________

ATT: ICOPHAI 2013 Sponsorship                                                      Exp. Date:___________________________

For more information, please visit our website http://icophai2013.org/ or email queries to info@icophai2013.org