PHIMA | Pennsylvania Health Information Management Association

2009 PHIMA Annual Meeting
The Penn Stater Conference Center Hotel
State College, PA
May 18-20, 2009

"Searching for a Better Tomorrow"

Exhibitor Registration Form

1. Complete the demographic information below.

* Company:

Are you a PHIMA Corporate Sponsor? Yes No Learn more

Contact Information

* First Name:

* Last Name:

* Address 1:

Address 2:

* City:

* State:

* Zip Code:

* Phone:

Fax:

* E-mail:

Website:

Attendance

How many representatives will be in attendance?

Name Badges

Please list the participants that will require name badges.


	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

	First Name	Last Name

2. Booth Selection and Special Events

Booth

View the Floor Plan

What are your choices for preferred booth number? Premiere Booths are denoted with an asterisk.

1st choice
2nd choice
3rd choice

Packages - Items included in the booth packages

Basic Single Booth (before 2/1/09 $650; after 2/1/09 $775 )

Premiere Single Booth (before 2/1/09 $1200; after 2/1/09 $1,375)

Double Premiere Booth (before 2/1/09 $1500; after 2/1/09 $1,675)

Utilities Needed for Booth

Electricity needed? Yes No

Internet access needed ? Yes No

Monday President's Reception

To assist PHIMA with planning for this event, please indicate how many representatives will be attending this Monday event. Additional tickets can be purchased for this event.


	Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included

Breakfast Tuesday Morning

To assist PHIMA with planning for this event, please indicate how many representatives will be attending this Tuesday event. Additional tickets can be purchased for this event.


	Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included

Tuesday Appreciation Luncheon

To assist PHIMA with planning for this event, please indicate how additional tickets will be needed for this Tuesday luncheon. Additional tickets can be purchased for this event.


	Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included

Tuesday Vendor Reception

To assist PHIMA with planning for this event, please indicate how many representatives will be attending this Tuesday evening event. Additional tickets can be purchased for this event.


	Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included

3. Sponsorships

If you are interested sponsoring an event or item for the meeting,
please check the applicable box below.

Sponsorship Opportunity	Cost	Benefit
President’s Reception	$2,500	Company Sign & Literature will be displayed in the break area and noted in the Program Book.
Vendors' Reception	$2,500	Company Sign & Literature will be displayed in the break area and noted in the Program Book.
Tuesday Breakfast	$1,000	Company Sign & Literature will be displayed in the break area and noted in the Program Book.
Tuesday All Day Break	$1,000	Company Sign & Literature will be displayed in the break area and noted in the Program Book
President Reception Entertainment	$500	Company Sign & Literature will be displayed in the area and noted in the Program Book
Wednesday Breakfast	$1,000	Company Sign & Literature will be displayed in the breakfast area and noted in the Program Book.
Wednesday AM Break	$500	Company Sign & Literature will be displayed in the break area and noted in the Program Book
Wednesday Luncheon	$1500	Company Sign & Literature will be displayed in the breakfast area and noted in the Program Book.
Keynote Speaker	$1,500	Company Sign & Literature will be displayed at the break area and noted in the Program Book
Product Donation – Name Tag Neck Wallets (with your Company Logo)	$1,500	Company’s donation will be noted in the Program Book.
PHIMA Scholarship Donation -	$500 per student	Company’s donation will be noted in the Program Book and a Company representative will sit with the student at a special table at the Tuesday Luncheon. A Company representative will present the award.
Product Donation – Binder/Bag (with your Company Logo)	$2500 full sponsorship or $1500 partial	Company donation will be noted in the Program Book.
Speaker	$300	Allows you to introduce speaker, provide literature in education session and have your name or Logo posted in meeting room.

4. PHIMA Website Vendor Information

The information completed in this section will be published in the PHIMA
vendor book as well as published on the PHIMA website. We will not be publishing logos or ads this year.

Please list any changes from the contact information provided above that you would like printed differently in the program (e.g. contact name, phone number or email address).

*Contact Name
Phone Number
Email Address

Company Description

Enter a concise, 2 paragraph description.

5. Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the cancellation policy, insufficient check funds policy, and exhibitor agreement.

6. Questions or Comments

Do you have a question or comment? Please enter below and we will contact you.

Payment options include: Check or credit card

1. Complete the demographic information below.

* Required information

5. Acceptance of Terms and Conditions

6. Questions or Comments