Register today! Sponsorships are available!

[ ] Visionary ($20,000) [ ] Platinum ($15,000) [ ] Gold ($10,000) [ ] Silver ($5,000) [ ] Bronze ($3,000) [ ] ___ seats ($150/person)
Method of Payment: [ ] Check enclosed [ ] Check sent (faxed replies only) [ ] Pay at the door [ ] Credit Card

Attendee Name(s): ____________________________________________________________________________________________

Affiliation:_____________________________________________________________________________________________________

Address: ____________________________________________________City, State, Zip: ___________________________________

Email: _______________________________________ Phone: ____________________________ Fax: ________________________

Credit Card: [ ] Visa [ ] MasterCard [ ] American Express Name, as it appears on card: ____________________________________

Credit Card Number: __________________________________________________ Expiration Date: ___________________________

To RSVP or for more information please contact 631-261-0242, info@visionlongisland.org or fax 631-754-4452.