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Mirrors Sponsorship Form

LOS ANGELES COUNTY PSYCHOLOGICAL ASSOCIATION

 

Sponsorship: MIRRORS OF THE MIND 5: THE PSYCHOTHERAPIST AS ARTIST

 

November 2 – 13, 2016

RECEPTION: Saturday, November 5th         5:00 - 9:00 PM           Held at Art Share LA

Patrons will receive a grateful acknowledgment at the gallery event, on Mirrors 5 event advertising and announcements, and will be listed as a sponsor on the LACPA website.

 

Gallery Patron                                           $1000

 

Poetry Event Patron                                $ 500

  

Supporters will receive grateful acknowledgement at the gallery event and on LACPA Mirrors 5 event advertising and announcements.

Platinum Level Supporter                     $300

Gold Level Supporter                              $200

LACPA does not endorse any of the products, programs, or services advertised.

 

Individual or Company Name: _____________________________________________________________

 

Sponsorship Amount: $ _______________________

Contact Person: _______________________________________________________________________

 

Web Address: _________________________________________________________________________

 

Mailing Address: _______________________________________________________________________

 

City/State/Zip: _________________________________________________________________________

 

Phone: (_____) _______________________                           FAX: (_______) ________________________

Email: _____________________________________________________________

 

Send check, with a completed copy of this form, made payable to LACPA, 6345 Balboa Blvd. Suite 126, Encino, CA 91316

Please note - Mirrors 5 Sponsorship - on your check

 

TO PAY WITH CREDIT CARD COMPLETE INFORMATION BELOW:

VISA/MASTERCARD ONLY Number: __________________________________________________________    EXPIRATION DATE__________________

 

THREE SECURITY NUMBERS ON BACK OF CARD __________  NAME AS ON CREDIT CARD __________________________________________

BILLING ADDRESS FOR THIS CREDIT CARD

STREET NUMBER_________________________________________________   CITY____________________________ ZIP CODE_______________________

 

FOR EVENT INFORMATION: go to www.lapsych.org, then click on the Mirrors tab on the home page

QUESTIONS: Contact Pamela McCrory, Ph.D., Co-Chair Community Outreach Committee: mccroryphd@earthlink.net

 

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