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* Complimentary RegistrationsPlease provide the names of the complimentary conference attendees below. Refer to the exhibitor and/or sponsorship packet information for the number of complimentary registrations. If your sponsorship allows for more than one complimentary registration, click on the plus button next to the first name to add more.Name of persons to receive complimentary registrationNameEmail Add RemoveProvide 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 - $2,500 Luncheon Sponsor - $2,000 Platinum Sponsor - $1,800 Gold Sponsor - $1,500 Conference Lanyard Sponsor - $1000 Conference Bag Sponsor - $2000 Name Badge Sponsor - $1000 Break Sponsor - $800 Will you be providing pre-printed inserts? (450 required)* Yes No Maybe Total HiddenPayment Option* Check Credit Card Payment Option* Check Credit Card Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 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 NameThis field is for validation purposes and should be left unchanged. Δ Annual ConferenceInformation General Info Location Hotel Information CE Information Registration & Payment Schedule Summit Schedule Pre-Conferences Session Schedule Sponsors & Exhibitors Sponsors Exhibitors Opportunities Sponsor Registration Exhibitor Registration & Other Options Student Volunteers