Conference Sponsor (Platinum) $1500.00 Conference Sponsor (Gold) $1000.00 Conference Sponsor (Silver) $500.00 Conference Sponsor (Bronze) $250.00 Vendors/Exhibitor Only $350.00 Other Sponsorship Select a Payment System Paypal/Credit Card - Secure credit card payment Offline (check) - online registration with check sent by US Mail Coupon Code Your First & Last name Choose a Login Name (User ID) It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_' check for uniqueness Your E-Mail Address A confirmation email will be sent to you at this address. IMPORTANT: This is the e-mail address where all official VAHQ communications will be sent. Confirm your E-Mail Address Choose a Password Must be 4 or more characters Confirm your password Enter password again Title Organization Street City State ZIP Country [Select country] United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands (British) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe Work Phone Alternate Phone Fax Type/Purpose of business:
Conference Sponsor (Gold) $1000.00
Conference Sponsor (Silver) $500.00
Conference Sponsor (Bronze) $250.00
Vendors/Exhibitor Only $350.00
Other Sponsorship
Your E-Mail Address A confirmation email will be sent to you at this address. IMPORTANT: This is the e-mail address where all official VAHQ communications will be sent.
Organization
VAHQ | P.O. BOX 71013 | Richmond, VA 23255-1013 ©2008, Virginia Association for Healthcare Quality
