Vermont Society of Health-System Pharmacists
Annual Meeting Sponsorship Request Form
April 14, 2012.

Please download, print, and remit payment with this form or submit your payment electronically below.

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Pharmaceutical Company:
Representative’s Name:
Sponsorship Options:	Major Program Sponsor - $795.00 Display Booth - $495.00

(Our tax ID # is 27-0616064)

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If you have any questions, you can reach Joanna Schwartz, Pharm.D., or Lisa Jackman, CPhT at the contact information listed below. Thank you for supporting the Vermont Society of Health-System Pharmacists’ educational program.

Joanna Schwartz, Pharm.D., BCOP President, VtSHh Phone: 802-735-2625 E-mail: joanna.schwartz@acphs.edu

Lisa Jackman, CPhT Secretary, VtSHP Phone: 802-847-9665 E-mail: lisa.jackman@vtmednet.org

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(Registration will not be completed until payment is submitted).