UERMMMC Medical Alumni Association of America, Inc.

&UERMMMC AFUSA, Inc. and Alliance & Friends

CO-HOST: MAAAI - So.CA Chapter

SOUVENIR PROGRAM ORDER FORM

UERMMMC-MAAA, Inc. & Alumni Foundation USA, Inc.
28th ANNUAL REUNION AND CONVENTION June 30 July 3, 2016
Newport Beach Marriott Hotel & Spa 900 Newport Center Drive,Newport Beach,CA 92660
On Line go to : www.SignUpMaster.com/uerm or https://resweb.passkey.com/go/UERM2016
For Printed Forms go to : www.uermafusa.org
:
Print Name or Company (as you would like it to appear in the program):

Billing Add:
Tel. No.

Fax:

Email:
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BACK COVER
$ 1,200.00
Back Inside cover
$ 1,100.00
Front Inside cover
$ 1,000.00
GOLD Sponsor Page List
$ 500.00 & UP
SILVER Sponsor Page List
$ 250.00 - 499.00
BRONZE Sponsor Page List
$ 100.00 199.00
ANGEL Sponsor Page List
$ 50.00 99.00
Deans Scholarship Fund (Donation from $100 & Up)
$ _______________
Dr. Wilmer Heceta Memorial 333 Endowment Fund (AFUSA)
$________________
Full Page Ad
$ 200.00
Half Page Ad
$ 150.00
One-Fourth Page Ad
$ 100.00
Send-in Digital Format (JPEG or Pdf ) to Dr.Andy de la Llana (310)901-3340 / andymd_uerm84@yahoo.com
Camera Ready AD enclosed / (___)Design an AD/Message for me (please add $50 for art/layout work
In-Kind Donation of: ______________________________________________Declared Value $ ____________
Please contact:Mrs.Esther Querubin (440)759-4599 / Email: reque@aol.com or
Mrs. Odette Blas (630)816-1171 / manuel.blas@aol.com

PAYMENT METHOD (Go to www.SignUpMaster.com/UERM or PayPal or mail or fax this form with payment):
CREDIT CARD PAYMENT: c/o Dr.Ma.Teresa G.Pas tor (310)707-8480 / Fax: (562)961-0212 / babesmd@gmail.com or thru PayPal
*VISA/MC/AMEX #
Exp. Date:
ID Code:
Print Name:

Position:

Signature:

Date Signed:
(As it appears on the card)

CHECK PAYMENT:
Make Check payable to:
Your donation is fully tax deductible to the extent allowed by law and IRS regulations.
UERMMMC-MAAA, Inc. Taxpayer ID # 52-1745846
UERMMMC-AFUSA,Inc. Taxpayer ID # 13-3119113

For more information:

UERMMMC-MAAA, Inc.
c/o Dr. Raul Moran, Treasurer
PO Box 2153 Bedford Park, IL 60499-2153
Tel.(703) 503-8181

Dr. Susan P. Suntay, Natl Convention Commissioner (312)523-6824 / spsuntaymd@gmail.com

Dr. Joselito P. Babaran, 2016 Convention Chairman (818)395-9478 / jp_babaran@yahoo.com

SOLOCITED BY: _________________________________________

DEADLINE FOR SUBMISSION: JUNE 15, 2016 (NO EXTENSION)

Thank you for your support!!!