REGISTRATION FORM

WESTMARC and
West Valley Chamber Alliance
Annual Luncheon with

Governor Jan Brewer

Please reserve:

Thursday, January 12, 2012

______ Gold/Silver/Bronze Sponsorship Level at $______________________

11:30 a.m. - 1:00 p.m.

Glendale Civic Center|5750 W. Glenn Drive |Glendale, AZ

______ Table Sponsor $600 each

______ Seat(s) at $60 each for Members
Chamber Affiliation for Member Pricing: _______________________
______ Seat(s) at $75 each for Non-Members

Sponsorship Levels
Gold

Table for 10 - Gold Preferred Seating

Additional Seat at Head Table
Logo Recognition on All Event Materials
Corporate Logo Scrolled During Event
Podium Acknowledgement at the Event
VIP Reception Admission

$2,500

Silver Table for 10 - Silver Preferred Seating

Logo Recognition on All Event Materials
Corporate Logo Scrolled During Event
Podium Acknowledgement at the Event

$1,500

Bronze Table for 10 - Bronze Preferred Seating

Corporate Name on Select Event Materials
Corporate Name Scrolled During Event

$1,000

Please provide Company information (please type):

__________________________________________________________________
Company Name

___________________________________________________________________
Address

___________________________________________________________________
City/Zip

___________________________________________________________________
Contact Name

___________________________________________________________________

Table Sponsorship
Table for 10 - Reserved Seating
Corporate Name on Table Sign

Please list attendees below (please type):

Individual Seat
Members
Non-Members

Phone

Email

$600

$60 / $75 At the Door

$75 / $90 At the Door

1. _________________________________________________________________
Name

_________________________________________________________________
Company

2. _________________________________________________________________
Name

_________________________________________________________________
Company

3. _________________________________________________________________
Name

_________________________________________________________________
Company

4. _________________________________________________________________
Name

_________________________________________________________________
Company

Credit Card Information (please type):

________________________________________________
Company Name

________________________________________________
Name on Card

________________________________________________
Mailing Address

________________________________________________
City

Zip

________________________________________________
Type of Credit Card

5. _________________________________________________________________
Name

_________________________________________________________________
Company

________________________________________________
Exp Date

CID

6. _________________________________________________________________

________________________________________________

_________________________________________________________________

________________________________________________

Name

Company

7. _________________________________________________________________
Name

_________________________________________________________________
Company

8. _________________________________________________________________
Name

_________________________________________________________________
Company

Credit Card #

Total Amount $

Receipt: Faxed or Mailed?

________________________________________________
Please Provide Fax Number or Address for Mailing Receipt

Make checks payble to WESTMARC or complete credit

card information above. No refunds after Dec. 31, 2011.
No phone/email reservations accepted.
Please deliver or fax completed form to:

9. _________________________________________________________________
Name

_________________________________________________________________
Company

10. _________________________________________________________________
Name

_________________________________________________________________

WESTMARC

Attn: Governors Luncheon 2012

14100 N. 83rd Ave, Suite 150, Peoria, AZ 85381
Fax: 623-435-0485

Company

WESTMARC | 14100 N. 83rd Ave, Suite 150 |

Peoria, AZ 85381 | 623-435-0431 | Fax 623-435-0485