Check if your sponsorship is made on behalf of the business
Mailing Address *
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Phone *
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Alternative Phone
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Payment Method *
Name on Credit Card
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Billing Zip Code
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Sec Code
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Credit Card #
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Contribution: I am unable to attend, but I wish to make a tax-deductible contribution to Physician Led Access Network of Collier County in the amount of $______
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Event Registration Card
Guest Names *
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A copy of your responses will be emailed to the address you provided.