2014 Benjamin Rush Blue Jean & Black Tie Gala

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]