The Keystone Dental Health Conference October 12-15, 2023 The 2023 Keystone Health Conference Corporate Vendor Registration Form Sponsor Registration InformationCompany Name Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company PhoneCompany Email Exhibitor's Name Exhibitor's PhoneExhibitor's Email Please select a sponsorship level: PLATINUM SPONSOR: Contribution of $1800 or higherIncludes: free signage, recognition on the PDHA website (logo and company webpage link), full-page ad (8” x 5”) in program book, 1 free exhibit booth, 2 tickets to the PDHA President’s Banquet GOLD SPONSOR: Contribution of $1200 or higherIncludes: free signage, recognition on the PDHA website (logo and company webpage link), full-page ad (8” x 5”) in program book, and 1 free exhibit booth. SILVER SPONSOR: Contribution of $750 or higherIncludes: free signage, recognition on the PDHA website (company webpage link), 1/2 page ad (4” x 5”) in program book, 1 free exhibit booth. BRONZE SPONSOR: Contribution of $500 or higherIncludes: free signage, recognition on the PDHA website, 1/2 page ad (4” x 5”) in program book, 1 free exhibit booth. CONTRIBUTING SPONSOR: Contribution of $300Includes, recognition on the PDHA website, 1/2 page ad (4” x 5”) in program book, 1 free exhibit booth Your exhibit registration fee includes an 8-foot skirted table and a continental breakfast.Platinum Sponsor Gold Sponsor Silver Sponsor Bronze Sponsor Contributing Sponsor Invoice Needed? Yes No Electrical outlet needed? Yes No Extension cord needed? Yes No Electric and/or Extension Cord Fee Price: Upload Ad and/or Logo (JPEG format) Drop files here or Select files Max. file size: 256 MB. If you're unable to upload your artwork today, please email company ad (JPEG format) or company logo (JPEG format) to Dana Shaffer [email protected] no later than August 12, 2023 to be printed in the program booklet.Credit Card Cardholder Name Card Details Total Credit Card Processing Fee Price: The 2022 Keystone Health Conference