TLPCA Counseling and Therapy Summit Sponsor Registration "*" indicates required fields Sponsor Registration ItemsName of Organization (as it will appear in the conference program):*Name of Contact Person to Receive All Sponsor Information:*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 Phone*Email* Business/Organization Website* Provide a business/organization description for the conference program.*File or Graphic for promotional purposes:* Drop files here or Select files Max. file size: 29 MB, Max. files: 3. DISCLAIMER* I agree.TLPCA does not provide a list of registrants or attendee contact information as part of any exhibit or sponsorship packages. Levels of Support and ParticipationOptions* Keynote Sponsor - $2,700 Luncheon Sponsor - $2,500 Platinum Sponsor - $2,200 Diamond Sponsor - $2,000 Gold Sponsor - $1,800 Silver Sponsor - $1,500 Bronze Sponsor - $1,200 Conference Lanyard Sponsor - $1000 Name Badge Sponsor - $1000 Break Sponsor - $1,000 Will you be providing pre-printed inserts? (450 required)* Yes No Maybe Complimentary RegistrationsPlease provide the names of ALL of the complimentary conference attendees below, including yourself. Refer to the sponsorship information for the number of complimentary registrations.Name of Person 1 to receive complimentary registration* First Last Email of Person 1 to receive complimentary registration* Enter Email Confirm Email Name of Person 2 to receive complimentary registration* First Last Email of Person 2 to receive complimentary registration* Enter Email Confirm Email Payment InformationTotal Payment Option* Check Credit Card Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Billing 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 EmailThis field is for validation purposes and should be left unchanged. Δ Annual ConferenceRegistration & Payment Summit General Info Schedule Keynote Location Hotel Information CE Information Call for Proposals Sponsors & Exhibitors Opportunities Sponsor Registration Exhibitor Registration & Other Options