Sponsorship Registration
Fall Conference 2026. (October 23-24)
Sponsor Contact Information
Company Name
Name and Contact Information of Main Point of Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Donation Details
Sponsorship Tier
Title Sponsor $12,000 (Only One Available - Confirm With Society Before Payment)
Diamond Partner $7500
Platinum Partner $5000
Evening Reception Sponsor $5000
Exhibitor Partner $2500
Breakfast Product Theater $9000
Extra Exhibitor Passes $200 Per Badge (Limit One Additional Per Sponsorship)
Other
Sponsorship Amount
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USD
Description
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Sponsorship Purpose
Event Sponsorship
Program Sponsorship
Other
Additional Comments
Attendee Full Name
First Name
Last Name
Attendee Email Address
example@example.com
Attendee Company
Attendee Full Name
First Name
Last Name
Attendee Email Address
example@example.com
Attendee Company
Attendee Full Name
First Name
Last Name
Attendee Email Address
example@example.com
Attendee Company
Attendee Full Name
First Name
Last Name
Attendee Email Address
example@example.com
Attendee Company
Attendee Full Name
First Name
Last Name
Attendee Email Address
example@example.com
Attendee Company
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Mailing Address for Payment by Check
Louisiana Dermatological Society: 2270 Eliza Beaumont Lane, Baton Rouge, LA 70808
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