Missouri Mine Safety

D O N A T I O N / S P O N S O R    F O R M

Tan-Tar-A Resort, Osage Beach, Mo.
DATE - January 11 - 12, 2018


Please fill out the form below or download the

and submit with your payment.

Yes, we would like to support the Conference with our tax-free donation!
Pay By Credit Card     Pay By Check
Company Name:
Company Contact:
Office Phone:
Cell Phone:

* Meal Sponsorship: Meal sponsorship will include verbal recognition during the conference, and special recognition in the program agenda for all sponsoring company attendees. Note: If you agree to provide at least half the cost of a meal function, we will list you as a partial sponsor or co-sponsor.

Breakfast Sponsor on January 12th - (approx. $4,500)

Lunch Sponsor on January 12th - (approx. $6,000)

Breakfast Sponsor on January 13th - (approx. $4,500)

* Sponsorship Levels: All sponsorship levels will receive substantial acknowledgement.
(Please specifiy dollar amount of sponsorship)

$ Platiunum ($3000 +)
(Includes 5 Free $180 registrations)
Bronze ($500 - $999)
  Gold ($2000 - $2,999)
(Includes 3 Free $180 registrations)
Iron Ore ($200 - $499)
  Silver ($1000 - $1,999)
(Includes 1 Free $180 registration)
Ryholite ($25 - $199)

Sponsorship Total + Meal Sponsorship: $
Type verification image: verification image, type it in the box

Respond by Dec. 3.  Checks must be received by Dec. 14 and made payable to:
Mo. Mine Safety & Health Conference (Tax ID # 20-4745989)
Mailing Address: P.O. Box 1725, Jefferson City, MO 65102
Phone 573-635-0208 -- Fax 573-634-8006

We thank you for your support!

Privacy Policy