Medical Director Sponsor Registration Medical Director Sponsorship Registration If you are human, leave this field blank. Company Details Company Name * Name of Contact * Phone * Email * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Does your company or organization require provisions or restrictions for sponsorship monies? * Yes No Please Describe: * Medical Director Meeting Details Date * February 1, 2019 May 21, 2019 September 12, 2019 December 5, 2019 Title of Presentation * Please submit an electronic sponsor logo and title of your presentation along with a 50 word or less description of your organization. Company Profile Description (50 words or less): * Company Logo * Drop a file here or click to upload Choose File Maximum upload size: 100MB Participants Participant 1 Name * Title * Phone * Email * Participant 2 Name Title Phone Email Payment and Terms Is your company an OAHP Affiliate or Supporting member? * Yes - $5,000 No - $7,500 Which Member? * Access 2 Care Allergan AMAG Pharmaceuticals Amplifon Hearing Healthcare AstraZeneca Bayer Healthcare Biodesix Biogen CAQH CareCentrix Conexia, Inc. Delta Dental Dialyze Direct Exact Sciences Genentech Gilead Sciences HMA Merck Neurocrine Biosciences Newgen Software Novo Nordisk Optum OSU Health Plan Partners for Kids PerformRx Provide A Ride Sarepta Therapeutics Squire Patton Boggs UCB Pharma Vatica Health Veyo LLC Total to be processed: Payment Method * Check: Mail to OAHP, 230 E. Town St., Suite 200, Columbus, Ohio 43215 PayPal / Credit Card All cancellations for general or non-Convention OAHP Sponsorship opportunities MUST be received in writing by OAHP 45 days prior to the scheduled event to receive a refund less an amount equal to 25% of the total sponsorship amount. NO cancellations will be accepted or refunds issued once logos have been utilized on any promotional materials. By submitting this electronic form you provide OAHP the authority to charge the credit card provided and agree to all terms. Submit
