Thank you for your interest in sponsoring a satellite event during PAINWeek 2010.

Third-party companies (eg, medical education agencies, meeting planners, public relations, etc) working on behalf of a sponsoring company/commercial supporter must submit a Letter of Appointment on sponsoring company letterhead and signed by the company official listed, indicating that the third-party company is authorized to work and make decisions on behalf of the sponsoring company. Please mail letters and payments to:

PAINWeek
Attn: Redza Ibrahim
6 Erie Street
Montclair, NJ 07042, USA

You may submit an application form at any time to reserve space, however, date and time slot will not be confirmed until payment has been received by PAINWeek.

Instructions: Please complete this form. When complete press the 'Done' button. You will be sent a copy of this form to the e-mail address you provide below. Please save this for your records.

* Indicates required fields

	Form Completed by

1.	Your First Name*

2.	Your Middle Initial

3.	Your Last Name*

4.	Your Phone Number*

5.	Your Fax Number

6.	Your E-mail Address*

7.	Please select Event Type *

8.	Desired Date* Please note that breakfast programs are not available on Wednesday, and dinner programs are not available on Saturday.

9.	Are you planning on a meal function?*

10.	Is this a CME program?*