2018 Rural Health Legislative Day – Platinum-level Sponsor Payment by Check

Platinum Level – $1,000

  • Floor stand banner space
  • Two reps attend free
  • Signage

    First Rep Registration

    First Name*:

    Last Name*:

    Address*:

    City*:

    State*:

    Zip*:

    County:

    Employer:

    Title/Position:

    Work Phone*:

    Fax:

    Email*:

    Second Rep Registration

    First Name*:

    Last Name*:

    Address*:

    City*:

    State*:

    Zip*:

    County:

    Employer:

    Title/Position:

    Work Phone*:

    Fax:

    Email*:

    Payment Information

    Please mail your payment to:

    GRHA
    ATTN: Lloyd Sirmons
    365 Blount Road
    Waycross, GA 31503