Melting Mama's WLS Event - Sponsorship Registration
At The Boston Park Plaza Hotel and Towers - August 5 - 7, 2011
Company Name
*
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Abkhazia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
People's Republic of China
Republic of China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Company Phone Number
*
-
Area Code
Phone Number
Contact Name
*
First Name
Last Name
Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Abkhazia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
People's Republic of China
Republic of China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Contact Phone Number
*
-
Area Code
Phone Number
E-mail
*
Electronic Sponsorship Contract
This Agreement is made and entered into by and between Pouchworthy WLS Inc., hereinafter referred to as “CLUB,” and the Aboved Name Company hereinafter referred to as “SPONSOR.” PREAMBLE CLUB is holding and organizing the following event (“Event”): Description of Event: Melting Mama’s WLS event Boston Date(s) and Time(s): 6pm August 5, 2011 to 8am August 7, 2011 Location(s): The Boston Park Plaza Hotel and Towers 50 Park Plaza at Arlington St, Boston MA 02116 Number and Description of Participants: Upto 325 participants. SPONSOR is a principal supporter of this Event. The SPONSOR wishes to provide financial support for CLUB in return for which CLUB will provide to the SPONSOR a range of marketing opportunities and other services. The SPONSOR will receive maximum media exposure before, during and after this Event. SPONSOR support will go towards event transport and food, event management, marketing and promotion, and awards at the concluding awards ceremony and cash support of $AMOUNT STATED BELOW [SPONSOR agrees to pay for and supply ALL marketing materials (signage, flyers, give-a-ways etc.) in addition to the pledged dollar amount], more particularly set forth in Exhibit A and B (pages 10 and 11), attached hereto. It is hereby agreed between parties: 1. SPONSOR EXPOSURE CLUB will provide highest profiles to identify SPONSOR on all CLUB website pages, correspondence, announcements, banners/poster displays, support vehicle and ground support station signs, and selected promotional items (videos, internet broadcasts, flash trailers). CLUB shall provide the benefits to SPONSOR as set forth in the Exhibit A and B (pages 10 and 11), attached hereto 2. CLUB RESPONSIBILITIES CLUB will arrange staff to plan, organize, market, promote, conduct and evaluate the Event. CLUB will provide an endorsement disclaimer at the Event and on all promotional materials distributed in connection with the Event and recognize the SPONSOR and provide exposure as noted in the PREAMBLE. CLUB will adhere to the SPONSOR's rules, restrictions and goals, respecting their identity. This may be attached as an Appendix to this document and noted as such on this agreement. 3. SPONSOR RESPONSIBILITIES 3.1 The SPONSOR will provide CLUB in full within 10 days of this Agreement date, or on terms mutually-agreed-upon, and noted in an attached Schedule. 3.2 SPONSOR shall pay to CLUB the charges set out in Schedule 1 and pay any VAT properly levied on those charges. SPONSOR will pay all invoices for the charges within thirty days or their receipt. 4. PROMOTIONAL LIMITATIONS 4.1 Neither CLUB nor the SPONSOR shall have the right to use, in any way, the commercial or trade name, trademark(s), service mark(s), or other identification ("marks") of the other party without prior written consent of the other party. 4.2 The SPONSOR grants CLUB a royalty-free, non-exclusive license to use and display the identity of the SPONSOR and its associated marks (“Marks”) (unless limited by an Attachment). Such use shall be limited solely for the duration of sponsorship and any related advertising or promotional materials. CLUB and the SPONSOR acknowledge that provisions in this paragraph do not convey any right, title or ownership interest in marks. 5. TERM AND TERMINATION 5.1 Term. The agreement will start on the given date specified on the sponsorship order form and will continue until each party has discharged its obligations under the agreement unless terminated by either party in accordance with clause 5.2 and 5.3 . 5.2 Termination for Default. Either party may terminate the Agreement with immediate effect by giving written notice to the other if the other has committed a material breach of the Agreement and has failed to remedy of cure that breach within thirty (30) days of receiving written notice requiring rectification of the breach from the party not in the breach. 5.3 Termination for Convenience. Either party, by written notice, may terminate this Agreement, in whole or part giving 180 days notice to the other party. SPONSOR and CLUB may agree to a schedule of payments in those cases where the Agreement must be terminated due to cancellation of the event by the Event Manager or higher authority for any reason. Such agreement shall be added to this Agreement at the end thereof. If no such agreement is reached, SPONSOR is not entitled to any damages due to the cancellation of this Agreement. [CLUB may use any funds unused before on the cancellation of events to cover hotel cost and any other fees associaited to the event and material production. SPONSOR may pay liquidated damages to CLUB if SPONSOR cancels its participation. These damages will be limited to the dollar amount pledged by SPONSOR plus additional fees accrued for such cancellation additional fees could include but not limited to: Hotel cancellation charge, guest cancellation room and ticket charge, food and beverage charges etc.] 5.4 Termination of the Agreement shall not affect the accrued rights or liabilities of the parties arising out of the Agreement as at the date of the termination and all provisions which are expressed to survive this Agreement or by which by implication do so shall remain in force and effect. 5.5 Cancellations or Relocation of Event. a) In the event of cancellation or relocation of the Event due to circumstances within CLUB, Management or their representatives’ control, the liability of CLUB shall be limited to a refund of deposit fees paid to CLUB by the SPONSOR. b) In the event CLUB has no control over the cancellation or relocation of the Event, CLUB shall have no liability of any kind for deposits or fees paid by the SPONSOR. In the event of such termination, SPONSOR waives any and all claims for damages and agrees that the CLUB has no liability to return SPONSOR’s space fee, less SPONSOR’s pro rata share of all costs and expenses incurred and committed by the CLUB. 6. NO ENDORSEMENT Nothing in this Agreement should be construed to imply or convey CLUB’s approval, endorsement, certification, acceptance, or referral of any SPONSOR product or service. No materials developed or intended for use in connection with the sponsorship activities will be distributed or otherwise used prior to CLUB’s advance review and approval. According to the sponsorship selected, CLUB will provide appropriate acknowledgment and recognition of the SPONSOR in accordance with applicable laws. 7. REPRESENTATIONS AND WARRANTIES 7.1 By SPONSOR. SPONSOR represents and warrants that: a) It has the full corporate rights, power and authority to enter into this Application Agreement and to perform the acts required of it hereunder; b) Its execution of this Application Agreement does not and will not violate any agreement to which SPONSOR is a party or by which SPONSOR is otherwise bound, or any applicable law, rule or regulation; c) It will adhere to the information gathering, dissemination, privacy protection and other practices performed in such privacy policy as released by CLUB. 7.2 By CLUB. CLUB represents and warrants to SPONSOR that it has the full corporate rights, power and authority to enter into this Application Agreement and to perform the acts required of it hereunder. 8. INDEMNIFICATION 8.1 SPONSOR assumes entire responsibility and hereby agrees to protect, indemnify, defend and hold harmless CLUB and their respective officers, directors, members, employees, and agents against all claims, losses, and damages to persons or property, governmental charges or fines, and attorneys’ fees in connection with the sponsorship activities performed at the Event, excluding any such liability caused by the sole negligence of CLUB. 8.2 SPONSOR shall be fully responsible to pay for any and all damages to property owned by CLUB or managers which results from any act or omission of SPONSOR. 9. LIABILITY 9.1 SPONSOR agrees that CLUB’s liability (if any) on account of omissions or errors in such sponsorship or advertisement shall in no event exceed the amount of the charges for the sponsorship which was omitted or in which the error occurred and such liability shall be discharged by (abatement of the charges) or (a sponsorship allowance) commensurate with the error for the particular sponsorship in which the omission or error occurred, but in no event exceeding the contract price of the particular sponsorship in which the omission or error occurred. No adjustment is applicable to any free sponsorship. Reproduction quality of photographs or artwork provided cannot be guaranteed. 9.2 CLUB and/or SPONSOR are liable should one or the other default. Any 3rd party agency signing on behalf of the SPONSOR/exhibitor will be held responsible for the fulfilment of this non-cancellable contract. 9.3 The liability provisions in the Agreement do not apply to (a) death or personal injury resulting from negligence or (b) fraud or deceit in relation to which no restriction or constraint applies to CLUB or SPONSOR. 9.4 CLUB will not be liable in contract or tort or otherwise for (a) loss of profits, business or anticipated savings, or losses from wasted management time, whether such losses are direct or indirect; or (b) any indirect losses including but not limited to the indirect losses described in 9.4 (a) above, however such direct or indirect losses may arise may arise and even if SPONSOR has been advised of the possibility of such direct or indirect losses. 9.5 SPONSOR hereby agrees that any and all work conducted at the event site shall be performed in accordance with all applicable laws of the governing jurisdiction to provide a safe working environment for the Event workers and the general public. 9.6 CLUB and SPONSOR hereby agrees that SPONSOR is an independent contractor with respect to the CLUB and has no authority or power to incur debts, obligations or commitments of any kind whatsoever for or on behalf of the CLUB, or to bind the CLUB to any contract, agreement or employment agreement. SPONSOR agrees that Sponsor will pay all extra charges accrued which shall not be limited to: Internet access charges, electricity, special set-up or accommodations charges, hotel shipment and storage fees. 9.7 SPONSOR hereby agrees that any person or persons retained by the SPONSOR to work on or at the Event, will be employees of the SPONSOR and the SPONSOR will be solely responsible for any and all salary, wages, insurance and other benefits to which such employee(s) would be entitled under applicable laws, including but not limited to employment taxes and other deductions as may be required under law. 10. MISCELLANEOUS 10.1 Force Majeure. CLUB shall not be liable for any loss or damage arising from its failure to perform any of its obligations under this contract if such failure is the result of circumstances outside its control including but not limited to the outbreak of war, any governmental act, act of war, explosion, accident, civil commotion, riot, industrial dispute, strike, lockout, stoppages or restraint of labour from whatever cause, whether partial or general, weather conditions, traffic congestion, mechanical breakdown, obstruction of any public or private road or highway or any other force majeure, fire, flood or any other act of God. 10.2 Applicable Law. This Agreement shall be governed by and construed in accordance with the laws of the state of Massachusetts. All disputes arising out of this Agreement shall be resolved by the courts of Plymouth County. 10.3 Severability. If any provision of this Agreement shall be held invalid and unenforceable, such holding shall not invalidate or render unenforceable any other provision hereof. 10.4 Entire Agreement. This Agreement may be executed in counterparts, each of which shall be an original, and all of which together shall constitute one and the same instrument. This Agreement represents the complete understanding between SPONSOR and the Provider, and no amendments, deletions, or additions hereto shall be binding without written approval from both parties, unless otherwise specifically provided herein. 10.5 Independent Contractor. SPONSOR and CLUB shall be and act as independent contractors, and under no circumstances shall this Agreement be construed as one of agency, legal partnership, or joint venture of employment between CLUB and SPONSOR. None of the personnel under contract to, employed by, or volunteering for CLUB shall be deemed in any way to have any contractual relationship with SPONSOR whatsoever. CLUB shall be solely responsible for the conduct of its employees, personnel, and agents in connection with their performance of CLUB’s obligation hereunder. 10.6. Notices. All notices required or permitted hereunder shall be deemed duly given if sent by certified mail, postage prepaid, addressed to the parties as follows: If to SPONSOR: If to CLUB: 248 Bourne Road, Plymouth MA 02360 10.7 Assignment. This Agreement is not assignable in whole or in part by any party hereto in the absence of the prior written consent of the other party. IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed. SPONSOR is a principal supporter of this Event. The SPONSOR wishes to provide financial support at the level of:_Amount Below for CLUB in return for which CLUB will provide to the SPONSOR a range of marketing opportunities and other services as listed in exibit A & B pages 10-11. The SPONSOR will receive maximum media exposure before, during and after this Event as allowed. SPONSOR support will go towards event transport and food, event management, marketing and promotion, and awards at the concluding awards ceremony and cash support of $Amount Below made payable to Pouchworthy WLS Inc. within 5 days of the date of this agreement. SPONSOR agrees to pay for and supply ALL marketing materials (signage, flyers, give-a-ways etc.) Platinum Level $5,000 + vYour signs banner at the registration/event check in table. (Sponsor to provide banner) vYour Logo prominently featured on the Melting mama webpage and registration page. vYour Logo featured on the main Sponsors page. vYour Logo on the Exhibitor Page. vYour Logo featured on all guest communications. vYour Logo will be shown on the screen in the general session room prior, in between and after all sessions. (Sponsor to provide Logo for display and does not include the Friday evening and Saturday evening events) vUp to 8 Items inserted into the Melting mama event bag. vIncludes early Friday night set up of 1 Exhibitor table. vIncludes 1 Exhibitor table all day Saturday. vIncludes 10% off food at the Pairings Restaurant. (Saturday Only) vIncludes 2 VIP Amenity. (Item at cooks discretion) vName, Logo and Tag line shown on the welcome screen at the check in desk for all hotel and conference guest, visitors, and staff to see. (Friday Evening and Saturday All Day) vSponsorship acknowledged at event introduction. Gold Level $2,500 + vYour Logo prominently featured on the Melting mama webpage and registration page. vYour Logo featured on the main Sponsors page. vYour Logo on the Exhibitor Page. vYour Logo featured on all guest communications. vUp to 5 Items inserted into the Melting mama event bag. vIncludes early Friday night set up of 1 Exhibitor table. vIncludes 1 Exhibitor table all day Saturday. vIncludes 10% off food at the Pairings Restaurant. (Saturday Only) vIncludes 1 VIP Amenity. (Item at cooks discretion) vSponsorship acknowledged at event introduction vSponsorship acknowledged at event introduction . Silver Level $1,500 + vYour Logo prominently featured on the Melting mama webpage and the registration page. vYour Logo featured on the main Sponsors page. vYour Logo on the Exhibitor Page. vYour Logo featured on all guest communications. vUp to 3 Items inserted into the Melting mama event bag. vIncludes 10% off food at the Pairings Restaurant. (Saturday Only) vIncludes 10% off food at the Pairings Restaurant. (Saturday Only)
I have READ and agree to the Electronic Sponsorship Contract
*
Yes
No
Main Sponsorship Selections
Platinum Level $5,000 USD +
Gold Level $2,500 USD +
Silver Level $1,500 USD +
Other Opportunities
Opening Night Welcome Reception $8,500 USD
Saturday Lunch $8,000 USD
Saturday Night Main Event $9,500 USD
Seminar Sponsorship $3,000 USD
Item Sponsorship
Welcome Bags $1,500 USD + Bags
Room Key Welcome Pack $1,000 USD + Hotel Cost and Supplies
Seminar Water/Soda/Coffee $1,500 USD
Room Drop $1,000 + Room Drop Item
Pillow Cards $1,000
Seminar Note Pads $250 + Note Pads
Seminar Room Pens $250 + Pens
Exhibition Table
(1) 6' Table Saturday Only $900 USD (Set-up time 7AM; Take down time 10PM Saturday)
(1) 6' Table Friday (Set-up time 3pm Friday); Saturday (Take down time 10PM Saturday) $1,000 USD.
Platinum and Gold Sponsorship Company Logo Upload
Account Holder Name
*
First Name
Last Name
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Abkhazia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
People's Republic of China
Republic of China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Payment Type
*
Visa
MasterCard
American Express
Check: Make Payable to Pouchworthy WLS Inc
Credit Card Number
Authorized Charge Amount
Expiration Date Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Year
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
CVV Code
Payment Terms and Conditions
Credit Card Single Payment Agreement ** I authorize Pouchworthy WLS Inc. to charge the credit card indicated in this web form, for the noted amount on today’s date. This payment is for Sponsorship Services at the Melting Mama WLS Event Boston and or AD space on www.meltingmama.net or for goods/services purchased through www.meltingmama.net. I understand that returns, refunds and cancellations are not allowed. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form. **** Credit Card Recurring Payment Agreement **** I authorize Pouchworthy WLS Inc. to debit the credit card account indicated in this web form, for the noted amount on the schedule indicated. This payment is for AD space on www.meltingmama.net or for goods/services purchased through www.meltingmama.net. I understand that returns, refunds and cancellations are not allowed. I understand that this authorization will remain in effect until the schedule end date, or until I cancel it in writing which ever comes first, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form. **** ACH Single Payment Agreement **** I authorize Pouchworthy WLS Inc. to debit the bank account indicated in this web form, for the noted amount on today’s date. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute merchant debiting my checking/savings account, so long as the transaction corresponds to the terms indicated in this web form. **** ACH Recurring Payment Agreement **** I authorize Pouchworthy WLS Inc. to debit the bank account indicated in this web form, for the noted amount on the schedule indicated. I understand that this authorization will remain in effect until the schedule end date, or until I cancel it in writing, which ever comes first, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account each period as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company’s recurring billing with my bank so long as the transaction corresponds to the terms indicated in this agreement. * Cost: This invoice reflects the agreed upon cost for advertisement on meltingmama.net for a period of 30 days. This agreement is between the invoiced company and Pouchworthy WLS Inc. * Delivery arrangements: Invoiced Client and Pouchworthy WLS Inc agree that the delivery of service is of an AD placement on meltingmama.net, for a period of 30 days, unless noted otherwise. * Payment terms: Payment in full is required within 15 days of the invoice date. * Pouchworthy WLS Inc. will charge a late fee of 1% to all outstanding balances greater than 30 days past due. Pouchworthy WLS Inc. will charge a fee of $25.00 for all dishonored payments made for Sponsorship Services at the Melting Mama WLS Event Boston and or services provided by Pouchworthy WLS Inc
I Agree To The Payment Terms and Conditions:
*
Yes
No
Electronic Signature Notice
By using this web site, you agree to use an electronic signature in lieu of a paper-based signature. You understand that electronic signatures, just like your signing a piece of paper, are legally binding in the United States and in other countries. You further agree not to electronically sign any form without first reading it and ensuring you have accurately filled out the form to the best of your knowledge, thus demonstrating that you are able to access the electronic information used by our system.
Electronic Signature Agreement
*
Yes
No
Full Name
*
Prefix
First Name
Last Name
Date and Time Signed
*
-
Month
-
Day
Year
at
/
Hour
Minutes
AM
PM
Special Instructions for Event Management Team
Enter the message as it's shown
*
Submit Form
Should be Empty: