2014 Benjamin Rush Blue Jean & Black Tie Gala November 21, 2014 Bala Golf Club, Philadelphia, PA Program Advertisement and Gala Sponsorship Form Company Name:___________________________________________________________________________________ Contact Name: ____________________________________________________________________________________ Address: _________________________________________________________________________________________ Telephone: ______________________________________ Email: __________________________________________ Program Booklet Advertisement Please select your advertising size below. Camera-ready artwork must be submitted with this contract. Artwork may be submitted electronically to [email protected] using .jpg, .pdf, or .tif formats and black ink only. The deadline for advertising artwork is October 24, 2014.  $500 Back Cover (8”h x 5”w)  $400 Full Page (8”h x 5”w)  $450 Inside Front Cover (8”h x 5”w)  $300 Half Page (4”h x 5”w)  $450 Inside Back Cover (8”h x 5”w)  $200 Quarter Page (2”h x 3 1/2”w)  In addition to our purchase of an advertisement, we would like to contribute $______ toward the registration fee of a resident psychiatrist. Gala Sponsorship  $3,000 per sponsorship. Your organization or institution will receive an exhibit table, entry for two representatives, thank-you acknowledgement on signage posted throughout the event and in our program booklet, and a sign at a table designated for residents. This sponsorship will defray the cost of entry for 10 residents who are training in Philadelphia area health systems. Sponsorship deadline is October 24, 2014. Authorized Signature: ___________________________________________ Date:______________________ Method of Payment  Check enclosed, payable to the Philadelphia Psychiatric Society  Credit Card: (circle one) Visa MasterCard Discover American Express Name on Card:____________________________________________________________________________________ Billing Address for Card: ____________________________________________________________________________ Credit Card Number: ___________________ CVV #: ______ Expiration Date:________ Amount: ________ Authorized Signature: ______________________________________________________________________________ Please return this form with payment to: Philadelphia Psychiatric Society 777 East Park Drive, Harrisburg, PA 17111 Phone: (888) 723-2501 ● Fax: (717) 558-7841 ● Email: [email protected]