sponsorship application form - HIV-NAT

SPONSORSHIP APPLICATION FORM 20th Bangkok International Symposium on HIV Medicine January 17-19, 2018 Queen Sirikit National Convention Center Bangkok THAILAND

SPONSORSHIP PACKAGES PLATINUM

GOLD

SILVER

US$20,000 / THB700,000

US$15,000 / THB525,000

US$10,000 / THB350,000

includes Satellite luncheon date

includes Special discount 50% of satellite luncheon date

includes Special discount 25% of satellite luncheon date

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Free 2 standard booths



Free 4 full registrations



1) .......................................................

1) .......................................................

1) .......................................................

2) .......................................................

2) .......................................................

2) .......................................................

3) .......................................................

3) .......................................................

(please attach the name)



4) .......................................................

SATELLITE LUNCHTIME SYMPOSIUM

US$13,500 / THB472,500

January 17, 2018 Title : ............................................................................................................................................................................................ January 18, 2018 Title : ............................................................................................................................................................................................ January 19, 2018 Title : ............................................................................................................................................................................................ include

Free 2 full registrations (please attach the name) 1) ...............................................................................................

BOOTH EXHIBITION

2) ...............................................................................................

US$2,400 / THB84,000

Number of booth(s) : .................... include

Free 1 full registration (please attach the name) : ..................................................................

METHOD OF PAYMENT Telegraphic Tranfer

A/C name: A/C number: Bank name: Swift code: Address:

Cheque or Bank Draft

Please transfer to

HIV-NAT / Bangkok Symposium on HIV Medicine 045-2-61225-9 The Siam Commercial Bank Public Company Limited, Sapha-kachat Thai Branch SICOTHBK 1873 Henry Dunant Rd., Pathumwan, Bangkok 10330 Thailand

BILLING INFORMATION Name:

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Address: .................................................................................................................................................................................... .................................................................................................................................................................................... Phone:

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Email:

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Signature: ..............................................................................

Fax:

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Date: ..................................................................................