Application Date:  

Sponsor Name:  

Street:  

City/State/Zip:  

Contact:  

Title:  

Phone:  

Fax:  

Email:  

Sponsorship Level Requested:
  Platinum  $6,500
  Gold  $4,000
  Silver  $2,750
  Bronze  $1,500
  Web page link  $200
Other Sponsorship (please specify):  

Please make check payable to First Illinois Chapter HFMA and send to:

Julie Haluska
HFMA First Illinois Sponsorship Chairperson
1000 West Washington Blvd #202
Chicago, IL 60607
Telephone: (847) 800-2613
email: jhaluska@sbcglobal.net