2025 Day at the Capitol Sponsor Registration Form

2025 Day at the Capitol

Sponsor Registration Form

April 22, 2025

West Side of the Capitol | Sacramento, CA

Step 1

Organization Information

ORGANIZATION TO INVOICE*

ORGANIZATION FOR MATERIALS

This name will be displayed on all conference materials. You may skip if this is the same name as above.

NAME AND TITLE (main contact)*

The main contact listed will receive all important conference information. Please ensure that the contact details are correct, as this person is responsible for relaying this information to the necessary event registrants.

ADDRESS*

CITY*

STATE*

ZIP CODE*

PHONE NUMBER*

EMAIL*

Step 2

Level of Participation & Payment

2025 Conference Sponsorship Prospectus

SPONSORSHIP LEVEL*

This must be the level agreed upon with CPCA.

Note: Sponsorships do not include an exhibiting booth.

Step 3

Registration Personnel Information

Your Sponssorship comes with complimentary registrations, please provide the names of those individuals who will be attending the symposium. If your sponsorship comes with additional comped badges, email the names to sponsor@cpca.org.

NAME (REGISTRATION #1)

EMAIL (REGISTRATION #1)

PHONE (REGISTRATION #1)

NAME (REGISTRATION #2)

EMAIL (REGISTRATION #2)

PHONE (REGISTRATION #2)

LATE PAYMENT FEE*

In addition to the above sums, if any payment due is not timely made by the event date, in addition to the sum due there shall be a late payment penalty due in an amount equal to $100. Additionally, in the event payment is not received in full subsequently, additional $100 late fees will be assessed every 30 days after the event date until full payment and penalties are received.

Please acknowledge your agreement with the late fee policy by initialing below. Should you have any further inquiries, please feel free to reach out to us via email at sponsor@cpca.org

METHOD OF PAYMENT*

Select

I Agree to Send a Check to the Following:

California Primary Care Association

1231 I St. Suite 400

Sacramento, CA 95814

I Agree to Make Payment via ACH Transfer to the Following Bank Details:

First Citizen Bank

Accounting #: 009371385756

Routing #: 122037760

Name on Credit Card

Credit Card Number

Expiration Date

Billing Address

Invoice Me

Please list the email address for the person responsible for payment. Invoices must be paid in full by the event date or late fees will apply (find late fee language above).

Tax Information*

Tax Identification Number

IRS Code

IRS Code Section 501(c) Status (if applicable)

Step 4

Conditions & Agreement

Before checking this box, click here to review the terms and conditions of your application and contract via printable pdf.

Please save a copy for your records.

Signature*

By checking this box I certify that I have reviewed and agree to the terms and conditions.

Step 5

Tell us about yourself.

Logo Upload

Please submit your high-resolution logo (pdf or eps files preferred).

Drag and drop files here or

Exhibitor Information*

What category of service do you offer?

Confirmation Information

After completing and submitting this registration form, you will be officially registered as an exhibitor or sponsor for the 2025 Day at the Capitol. A confirmation email will be promptly sent to your provided email address, affirming your successful registration. Should you have any inquiries or require further assistance, please don't hesitate to contact us at sponsor@cpca.org. We look forward to welcoming you at the event in April!

Please save a copy for your records.

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