Sponsor Order Form Sponsor Level* Premier ($7,500 / yr) Partner ($5,000 / yr) Chapter ($3,000 / yr) Company Name* Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Company Phone*Marketing Contact* Marketing Email Regional Contact or Listing Name The contact name as it should appear on your sponsor page.Listing Name Email The email to use for your sponsor page.Website Address The website address (URL) to link from your sponsor page.Company Overview*Provide a brief company overview highlighting products and servicesCompany LogoMax. file size: 50 MB.If available, please upload your company logoCoupon Method of Payment* Pay Online (PayPal) Pay by Check Total $0.00 Once you select submit, you are agreeing to Pay by Check. Please mail your check to: SC HIMSS c/o Abby Kazley 1724 Canyon Oaks Dr Mt Pleasant, SC 29464 Δ
