ICOPHAI 2015 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
Make checks payable to: Local Bank Transfer Credit Card Type:
The Ohio State University Siam Commercial Bank Public. comp. Ltd Visa Mastercard American Express
College of Veterinary Medicine Acct. No.: 667-400878-7 Print name:__________________________
1920 Coffey Rd Swift Code: SICOTHBK Signature:___________________________
Columbus, OH 43210 ACCT. NAME: FVM-CMU for ICOPHAI2015 Number:____________________________
ATT: ICOPHAI 2015 Sponsorship Exp. Date:___________________________