Dakota Conference Sponsor Registration - CLOSED

Display space is limited – sign-up now!
Deadline: March 13, 2012 at noon

Sponsorship Levels (comes with an exhibit space)

My organization will sponsor the Dakota Conference at the following level:
	Bronze	= $500
	Silver*	= $750
	Gold*∞	= $1000
Space and location determined by order of registration and level of sponsorship.
* The sponsoring organization's logo should be emailed in a tiff, jpeg, PDF, or    eps file format and be at least 200dpi for use in conference materials. The    logo must be submitted to kylie.nissen@med.und.edu at the time of    registration.
∞ One page ad (8½ x 11) color or black/white designed & submitted by the     sponsoring organization, must be emailed in a PDF file format to     kylie.nissen@med.und.edu by noon on March 8, 2012.

Additional Items/Events

	Break Sponsor = $500
	Name Tag/Lanyard Sponsor* = $900
	Opening Reception Sponsor* = $1,000
	Conference Totes/Bags Sponsor*= $1,500
	Awards Banquet Sponsor* = $2,000
	Keynote Sponsor = $2,000
	Advertisement in Conference Program (select one)
	Half page (7 1/2 x 5)^ - $425
	Quarter page (3 3/4 x 5)^ - $425
*	The sponsoring organization's logo should be emailed in a tiff, jpeg, PDF, or eps file format and be at least 200dpi for use in conference materials. The logo must be submitted to kylie.nissen@med.und.edu at the time of registration.
^	Advertisements must be created and submitted by the sponsoring organization to kylie.nissen@med.und.edu by noon on March 8, 2012. The ads should be at least 200dpi and should be emailed in a tiff, jpeg, PDF, or eps file format.

Organization Contact Information:

Please print information as you would like it to appear on all printed materials.
Organization:
Contact Name:
Title:
Address:
City/State/Zip:
Phone:
Fax:
Email:
Please provide a description of company/organization in 30 words or less (may be used in promotional materials). *Descriptions that run more than 30 words will be truncated at the 30 word point.

Display Space at the Dakota Conference:

	Our organization will not be displaying at the conference. Please note: If you will not be exhibiting at the conference, but would like a flyer or brochure set out for participants, please contact Kylie at kylie.nissen@med.und.edu.
	Our organization will be displaying an exhibit at the conference. Bronze and Silver level registrants receive one complimentary registration for their display representative. Gold level sponsors receive two complimentary registrations for their display representatives. Only one exhibitor may use the complimentary conference registration. It may not be different people at different days/times. The person designated to receive the complimentary registration must be listed on the registration form and may not be changed after noon on April 26.
Please check boxes if you require these additional items:
Electricity-add'l $15/day Wednesday Thursday Total$ Internet-add'l $10/day Wednesday Thursday Total$ If you will be displaying at the conference, you are responsible for bringing all supplies including extension cords for setup. **Notification of any changes in exhibitors or conference registrants must be received by the Center for Rural Health by noon on April 26, 2012.**

Exhibitor 1:

Check if same as organization contact (be sure to complete the requested information under the contact info)
Name:
Title:
Address:
City/State/Zip:
Phone:
Fax:
Email:

Please select meals that you will be attending:
Wed., 5/30 Lunch PM Break Reception	Thurs., 5/31 Breakfast AM Break Lunch PM Break	Fri., 6/1 Breakfast AM Break
I would like to attend the awards banquet (May 31, evening)      Tickets are $25 each. # of tickets
I will be attending the CAH Quality Network/Flex Pre-Conference      (May 30, 8:30-11:30 am)
I will be attending the NDPHA Pre-Conference (May 30, 8:30-11:30 am)
Please provide a written request for any special needs (including dietary)

Exhibitor 2: (Gold Level Only)

Name:
Title:
Address:
City/State/Zip:
Phone:
Fax:
Email:

Please select meals that Exhibitor 2 will be attending:
Wed., 5/30 Lunch PM Break Reception	Thurs., 5/31 Breakfast AM Break Lunch PM Break	Fri., 6/1 Breakfast AM Break
I would like to attend the awards banquet (May 31, evening)      Tickets are $25 each. of tickets
I will be attending the CAH Quality Network/Flex Pre-Conference      (May 30, 8:30-11:30 am)
I will be attending the NDPHA Pre-Conference (May 30, 8:30-11:30 am)
Please provide a written request for any special needs (including dietary)

Method of Payment:

Confirmation will be sent upon receipt of payment. All payments are nonrefundable.
	Please send me an invoice. Total amount $
	Check # enclosed for $ is in the mail. Please make checks payable to UND-CRH.
	Submit with payment by March 13, 2012. Mail: Dakota Conference Center for Rural Health UND School of Medicine Room 4109 501 N. Columbia Rd. Stop 9037 Grand Forks, ND 58202-9037 Fax: 701-777-6779

Questions?
For questions contact:
Kylie Nissen, Project Coordinator
UND School of Medicine and Health Sciences
Center for Rural Health
701-777-5380
kylie.nissen@med.und.edu or
visit: http://ruralhealth.und.edu/dakotaconference/