Sponsorship Enrollment

IDAHO CHAPTER HFMA

CORPORATE SPONSHORSHIP PROGRAM

TAX ID. NO. 23-7017065

My firm would like to obtain/renew our Corporate Sponshorship with the Idaho Chapter of HFMA for the fiscal year as follows:

____ Platinum	$1,400	4 Registrations
____ Gold	$1,100	3 Registrations
____ Silver	$800	2 Registrations
____ Bronze	$500	1 Registration

Method of Payment:   ____ Check (Payable to: Idaho Chapter HFMA)

Name:	_______________________________________________________
Signature:	_______________________________________________________
Firm (Co. Name):	_______________________________________________________
Address:	_______________________________________________________ _______________________________________________________ _______________________________________________________
Telephone:	_______________________________________________________
Fax:	_______________________________________________________
E-Mail:	_______________________________________________________

 Please return completed form with check to:

Carla Terry, VP of Finance

Idaho Hospital Association

P O Box 1278

Boise, ID 83701-1278