Sponsorship Form

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:___________________________