GBR-ASSP Sponsor Sign Up

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* 1. Organization Name:

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* 2. Street Address:

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* 3. City/Town:

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* 4. State:

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* 5. Zip Code:

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* 6. Sponsor Representative Name:

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* 7. Phone Number:

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* 8. Email Address:

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* 9. Company Website:

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* 10. Sponsorship Level

Premier Sponsor - $1000

Supporting Sponsor - $500

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* 11. Company Logo - should be 130 px by 48 px

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.