EmailMe Form - *Sponsor and Exhibitor Registration 2023

Organization *

Name of Contact Person *

First Last

Email *

Phone

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Sponsor Level

Sponsor Amount

$ Dollars . Cents

Exhibitor Amount

$ Dollars . Cents

Signature of Contact Person *

Date *

MM / DD / YYYY

Payment Option *

Paying via PayPal Make payment to info@illinoisfreeclinics.org

Paying by Check: Please make check payable to Illinois Association of Free and Charitable Clinics 42 Steven St. #416 Lemont, IL 60439