Florida School of Addictions Studies, Inc.
SCHOLARSHIP DONOR, SPONSOR, ADVERTISER REGISTRATION & SELECTION FORM
(Please Print)

Name of Agency or Individual:___________________________________________________________________________

Mailing Address:_______________________________________________________________________________________
(P. O. or Street Address City State Zip)

Contact Person:_________________________

Day Phone #: (____)_________________

Fax # (_____)___________________

SCHOLARSHIP OR SPONSOR SELECTIONS
(Please check all that apply)

( ) Corporate Sponsor $3,000 (includes 1 exhibit space & recognition at the school) $___________
( ) Speaker Sponsor or Co-Sponsor Minimum $1,000 (includes 1 exhibit space) $___________
( ) Full Course Sponsor $2,500 (includes 1 exhibit space & 1 20-hour scholarship for 2008 FSAS) $___________
( ) Mini Course Sponsor $1,500 (includes 1 exhibit space & 1 10-hour scholarship for 2008 FSAS) $___________
( ) Breakfast or Dance Sponsor $1,200 (includes 1 exhibit space) $___________
( ) Lunch Sponsor $2,000 (includes 1 exhibit space & 1 20-hour scholarship for 2008 FSAS) $___________
( ) School Reception, Refreshment Break Sponsor $1,000 (includes 1 exhibit space) $___________
( ) Student Scholarship $275 each for Full Track or $170 each for Mini Track $___________
( ) Literature Stuffing Service $35.00 per title to be placed in student packets $___________
( ) Literature for “Take One” Table $25 per title made available to all attendees $___________

TOTAL PAYMENT DUE $___________

If your sponsorship donation includes exhibit space, please indicate your selection(s) below and include exhibitor information form. If your sponsorship donation includes a 10-hour or 20-hour scholarship, please indicate below. The FSAS Scholarship Committee will assign your generous donation to a worthy applicant.

____ FREE Exhibit Space ___ 10-Hour Scholarship ___ 20-Hour Scholarship

I(we) hereby submit our registration information as a scholarship donor/event sponsor at the 2008 Florida School of Addictions Studies.

Signed:____________________________________________

Date Signed:_____________________________

Name Printed:___________________________________________

Title:____________________________________

Please make checks payable to Florida School of Addictions Studies and mail with this form to:
FSAS Registrar
Florida School of Addictions Studies
1725 Art Museum Drive
Jacksonville, FL 32207

To pay with CREDIT CARD, please include the following information and fax completed form to FSAS Registrar at (904) 399-8001.

Card Type: ____________________

Card Number:_________________________________

Date Expires:___________

Name of Card Holder:_____________________________

Authorized Signature:__________________________