ARN Industry Partnership Sign Up

1. COMPANY INFORMATION

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State ZIP Code

2. CONTACT INFORMATION

Your Name(Required)

First Last

Your Title(Required)

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone number(Required)

Your Email(Required)

3. INDUSTRY PARTNERSHIP TIER CHOICE

Tiers(Required)

Platinum ($80,000)

Diamond ($60,000)

Gold ($30,000)

4. AGREEMENT & AUTHORIZATION

I am an authorized representative for this company with full power and authority to sign this application for 2023 ARN Industry Partnership. The company also agrees to comply with all rules and regulations outlined in the Industry Partnerships Overview Document, as well as all policies added after the publication of the document, which you accept as part of the agreement. This partnership will be active from 1/1/2023 if payment was received in 2022 or on the date payment was received in 2023 until 12/31/2023. ARN will make its best effort to fulfill the benefits outlined partnerships overview document (page 7). Restrictions and limitations can be found on page 15 of the aforementioned document. All benefits must be used by December 31, 2023.(Required)

Please type your full name. This serves as a signature.

Date of signature(Required)

5. PAYMENT

Please choose how you would like to pay:(Required)

This will be for the amount of the tier that you chose for #3 above.

Credit card

ACH/Wire

Check

Once we receive this document, we will invoice you through our payment processing platform, Stripe.

ARN ACH Information:

Bank Name: SouthState Bank
Account Name: American Rheumatology Network
Account #: 8010000595195
ACH Routing #: 053200983
Wire (origination and receiving): same as ACH, no different routing #

Please include your company name + "2023 Industry Partnership" in the memo line and remit payment to:

American Rheumatology Network
ATTN: Nicholas Stoltmann
2015 2nd Ave, Suite 204
Summerville, SC 29486

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ARN Industry Partnership Form

ARN Industry Partnership Sign Up

1. COMPANY INFORMATION

2. CONTACT INFORMATION

3. INDUSTRY PARTNERSHIP TIER CHOICE

4. AGREEMENT & AUTHORIZATION

5. PAYMENT

Contact

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