Sponsor Form
(Please complete and return with payment)
4th Annual Fraud and Scam Awareness Seminar for Seniors
Organized by
Senior Education Ministries, Inc.-Terre Haute, Indiana
May 18, 2010
ISU Hulman Center – Terre Haute, Indiana

Yes, we want to participate in the 2010 Fraud and Scam Awareness Seminar for Seniors as indicated below:

DRIVEN To E “RACE”    FRAUDS AND SCAMS Seminar Sponsor

A. ______ Pace Car sponsor $10,000+ (one only)
B. ______ Platinum Exclusive Sponsor $2500+
C. ______ Gold Sponsor $ 1000+
D. ______ Silver Sponsor $ 500+
E. ______ Bronze Sponsor $ 250+
F. ______ Breakfast Sponsor
G. ______ Lunch Sponsor

Please indicate if you wish to waive any of the exhibitor benefits by initialing below.
_____ Exhibit Booth
_____ Advertisement

Please provide the following information, as you would like it to appear in the Exhibit Guide:

Organization Name _____________________________________________________________________________

Contact Person/Title ____________________________________________________________________________

Street Address _________________________________________________________________________________

City _____________________State ______________________ Zip Code ____________________

Telephone Number __________________Fax Number ___________________________________

Email Address ___________________________Web Site ________________________________

Description of organization: ______________________________________________________________________

Require Electrical Outlet? Yes/No ____________           Require Internet Service? Yes/No ___________

Payment method: __________Check            Check No. _________  Amount $ _______________

For Office Use:   Date received: __________ Payment $__________

Date confirmed: _____________ Electricity _______ Internet ________