38TH ANNUAL GALA & BUSINESS MEETING SHARE OUR PRIDE: CELEBRATE OUR WORKPLACE INDIAN AMERICAN MEDICAL ASSOCIATION - ILLINOIS IAMA-IL A Bipartisan U.S. Congressional Salute to Chicagoland Hospitals & CEOs 5:30 PM SATURDAY, NOVEMBER 17, 2018 ASHTON PLACE WILLOWBROOK, IL 60527 Sponsorship Details included in this packet for more information Contact: office.iamaill@gmail.com Opportunity to Reach thousands of Physicians in Illinois...
Indian American Medical Association, Illinois Clinic/Charitable Foundation: 2645 W. Peterson Ave, Chicago IL 60659 Tel: (773) 275-8630 Fax: (773) 275-8635 Office: 6853 Kingery Highway Willowbrook IL 60527 Tel/Fax: (630) 522-3990 Administrative Secretary: Heidi Garton office.iamaill@gmail.com www.iamaill.org Tax ID: 36-3333867 President Sreenivas Reddy, MD sgreddymd1@gmail.com President Elect Niranjana Shah, MD nshahmd@gmail.com Secretary Geeta Wadhwani, MD grwadhwani@gmail.com Secretary Elect Suneela Harsoor, MD drharsoor@gmail.com Treasurer Sidney Jain, MD sidney_jain@hotmail.com IAMA Charitable Foundation Chair: Azazuddin Ahmed, MD Education Committee Chair: Parmijit Romi Chopra, MD Membership Committee Chair: Deepak Bakane, MD Communications & PR Committee Chair: Jalaja Piska, MD Entertainment Committee Chair: Subhash Goyal, MD By-Laws Committee Chair: Sharad Khandelwal, MD Health Awareness Committee Chair: Meher Medavaram, MD Academic Affairs Committee Chair: Jay Joshi, MD Young Physicians Committee Chair: Rajan Shah, MD Resident Physician Committee Chair: Radhika Chimata, MD Medical Student Committee Auxiliary Committee Chair: Lalitha Reddy, MD Liza Jain Board of Directors Chair: Tapas Dasgupta, MD Samir Shah, MD Hemlata Bakane, MD Rajinder Arora, MD Kirti Talsanai, MD Marella Hanumadass, MD Ashutosh Gupta, MD Rohitkumar Vasa, MD Asok Ray, MD Suresh Reddy, MD Presidential Advisors Vemuri Murthy, MD Vijay Singh Dr. Vijay Prabhakar Global Health Committee Chair: Rohitkumar Vasa, MD Advisor: Vemuri Murthy, MD ACA & Health Reform Committee Chair: Utpal Parekh, MD Liaison Committee for CMS/ISMS/AMA Chair: Raj Lal, MD Legal Consultant T. Paul S. Chawla (Chawla & Ravani) Dear Potential Sponsor: Indian American Medical Association, Illinois (IAMA-IL) is a non-profit professional organization that represents thousands of physicians of Indian Origin in Illinois. These physicians are committed to professional excellence and providing quality care to the patients in our State. IAMA-IL offers members opportunities to interact with their community through events including our Hands-Only CPR Program, Health Fairs, and Community Health Education Seminars. IAMA-IL also helps oversee a completely free healthcare clinic through our charitable foundation. This community health clinic is located at 2645 W. Peterson Avenue in Chicago and is run by our IAMA volunteer physicians and student members, who generously give their time and skills to 3500 patients annually, free of charge. These services include free medications as well as basic tests. As the President of the Indian American Medical Association, Illinois, and on behalf of our Executive Committee and Board of Directors, it gives me great pleasure to announce our 38 th Annual Gala Banquet and Business Meeting on Saturday, November 17, 2018, at Ashton Place in Willowbrook, Illinois. I invite you to connect with IAMA-IL, our members, and friends through this event. IAMA-IL is in the planning stages of our 38 th Annual Gala and Business Meeting. As in the past, the success of our event has largely been due to the contributions of our sponsors who have gone out of their way to lend financial support to this event and our organization. Every year the money we raise has been utilized to continue our community health programs and to invest in the continued education of our physician members to aid them in providing excellent patient care. We hope we can count on your support. As a sponsor, your organization will receive positive exposure from media campaigns, event promotions and from the over 300 guests expected to attend this year s event. We have several different sponsorship opportunities available, and these are detailed in the following pages. All sponsorship packages are customizable to allow you to choose the best way for your organization to connect with IAMA-IL, our members, and friends. Thank you for your consideration, we are looking forward to hearing from you soon. Should you have any questions or require more information, please contact me at president.iamail@gmail.com or our Administrative Secretary at office.iamaill@gmail.com or 630-522-3990. With Appreciation, Sreenivas G. Reddy, MD President, 2018
Indian American Medical Association, Illinois Clinic/Charitable Foundation: 2645 W. Peterson Ave, Chicago IL 60659 Tel: (773) 275-8630 Fax: (773) 275-8635 Office: 6853 Kingery Highway Willowbrook IL 60527 Tel/Fax: (630) 522-3990 Administrative Secretary: Heidi Garton office.iamaill@gmail.com www.iamaill.org Tax ID: 36-3333867 IAMA Charitable Foundation Chair: Azazuddin Ahmed, MD Education Committee Chair: Parmijit Romi Chopra, MD Membership Committee Chair: Deepak Bakane, MD Communications & PR Committee Chair: Jalaja Piska, MD Entertainment Committee Chair: Subhash Goyal, MD By-Laws Committee Chair: Sharad Khandelwal, MD Health Awareness Committee Chair: Meher Medavaram, MD Academic Affairs Committee Chair: Jay Joshi, MD Young Physicians Committee Chair: Rajan Shah, MD Resident Physician Committee Chair: Radhika Chimata, MD Medical Student Committee Auxiliary Committee Chair: Lalitha Reddy, MD Liza Jain Board of Directors Chair: Tapas Dasgupta, MD Samir Shah, MD Hemlata Bakane, MD Rajinder Arora, MD Kirti Talsanai, MD Marella Hanumadass, MD Ashutosh Gupta, MD Rohitkumar Vasa, MD Asok Ray, MD Suresh Reddy, MD Presidential Advisors Vemuri Murthy, MD Vijay Singh Dr. Vijay Prabhakar Global Health Committee Chair: Rohitkumar Vasa, MD Advisor: Vemuri Murthy, MD ACA & Health Reform Committee Chair: Utpal Parekh, MD Liaison Committee for CMS/ISMS/AMA Chair: Raj Lal, MD Legal Consultant T. Paul S. Chawla (Chawla & Ravani) President Sreenivas Reddy, MD sgreddymd1@gmail.com President Elect Niranjana Shah, MD nshahmd@gmail.com Sponsorship Levels 38 th Annual Gala Banquet & Business Meeting Ashton Place, Willowbrook, IL Saturday, November 17, 2018 Take advantage of our sponsorship packages to create high-powered exposure. Grand Platinum Sponsor ($20,000) Keynote speaking opportunity for 5 minutes Dinner Tickets (20) with one Premium Table for the IAMA Gala & Recognition of Sponsorship. One Premium Booth, 2 Pages in IAMA Souvenir Book (includes inside of front cover recognition) Feature Ad on the Central Video Screen during the annual event ceremony Gold Sponsor ($15,000) Speaking opportunity for 3 Minutes. Dinner Tickets (10) with one VIP table for the IAMA Gala & Recognition of Sponsorship 1 Premium Booth, 1 Pages in IAMA Souvenir Book (Inside back cover recognition) Feature Ad on the Central Video Screen during the annual event ceremony Silver Sponsor ($10,000) Dinner Tickets (10) for the IAMA Gala & Recognition of Sponsorship 1 Page in IAMA Souvenir book, 1 Standard booth. Feature Ad on Central Video Screen during annual gala banquet Bronze sponsorship ($5,000) Dinner tickets (10) for the IAMA Gala. 1 color page in IAMA Souvenir book. Media Wall ($3,000) Your company logo included on our event media wall Booths: $500 Video display in the Hall $750 Booth & Half-Page Ad (Color) $1000 Booth & Full-Page Ad (Color) $1200 1 Standard Booth. 2 Complementary Banquet Tickets Souvenir Ads: $1500 Outside Back Cover Color $750 Premium Page Color $600 Full-Page Color $400 Half-Page Color Secretary Geeta Wadhwani, MD grwadhwani@gmail.com Individual IAMA Gala Tickets: Individual: $100 / Individual VIP: $150 Table of Ten: $1000 / VIP Table of Ten: $1500 Secretary Elect Suneela Harsoor, MD drharsoor@gmail.com Please complete attached sponsorship application form and send with a check payable to IAMA-IL Indian American Medical Association (IL), 6853 Kingery Highway, Willowbrook, IL 60527 If you have any questions or need further information, please email Dr. Sreenivas Reddy (President) sgreddymd1@gmail.com or IAMA Admin. Secretary office.iamaill@gmail.com or call @ 630-522-3990. Treasurer Sidney Jain, MD sidney_jain@hotmail.com
Indian American Medical Association - Illinois 38th Annual Meeting and Banquet on November 17, 2018 Sponsorship Form Sponsor Contact Information Name: Title: Company: Phone: Fax: Email: Address: City: State: Zip: Sponsorship Levels Grand Platinum Sponsor ($20,000) Gold Sponsor ($10,000) Silver Sponsor ($5,000) Bronze sponsorship ($2,500) Martini Bar with your company signage ($2,500) Booths: $500 Video displayed in the Banquet Hall $750 Booth & Half-Page Ad (Color) $1000 Booth & Full-Page Ad (Color) $1200 1 Standard Booth. 2 Complementary Banquet Tickets Souvenir Ads: $1,500 Outside Bank Cover Color $750 Premium Page Color $600 Full Page Color Individual IAMA Black Tie Gala Tickets: $100 Individual $1000 Table of Ten $150 VIP Individual Quantity: Quantity: Quantity: $1400 VIP Table of Ten Quantity: See Contract on Reserve of Page
Sponsorships are available on a first contracted, first choice basis. * Deadline for application & Ad material: November 1st, 2018 This application to participate as a Sponsor at the 2018 IAMA-IL Annual Meeting and Banquet will become a contract upon submission based on the rates, rules governing the event and general information included in this contract. All fees are due upon receipt of invoice. 100% of the net sponsorship fees are due prior to November 1st, 2018. In the event IAMA is not in receipt of payment as outlined above, IAMA reserves the right to reassign sponsorship participation. In the event of cancellation, IAMA shall determine the cancellation assessment. Cancellation does not relieve the sponsor of the obligation to pay the determined cancellation assessment fee. Mail this application form along with check payable to IAMA-IL Attention: Specifications for Ad materials: Indian American Medical Association (IL) 6853 Kingery Highway Willowbrook, IL 60527 Please send your print-ready advertisement material electronically to office.iamaill@gmail.com in one of the following formats:.jpg - at 300 pixels per inch (ppi) resolution or greater.pdf - at 300 dpi resolution or greater.eps - as Adobe Illustrator vector format or Photoshop at 300 dpi resolution or greater.doc - Microsoft Word format If you have any questions or need further information, please email the IAMA-IL President (2018) directly at president.iamail@gmail.com or the IAMA-IL Admin. Secretary at office.iamaill@gmail.com X Date: Client/Agency: Authorized Signature/Name/Title X Date: IAMA - Authorized Signature/Name/Title
Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 5 Address (number, street, and apt. or suite no.) 6 City, state, and ZIP code 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) Requester s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Date Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No. 10231X Form W-9 (Rev. 12-2014)