Please type or clearly print all sections of the form.  Be sure to keep a copy for your files. 

Organization:                                                                                                                       

Contact:                                                                       

Title:                                                                    

Address:                                                                                                                                          

Telephone:                                                  

Fax:                                                                          

E-Mail:                                                                                 

SPONSORSHIP LEVELS

Please check sponsorship level desired.

[  ] PLATINUM - $20,000  

[  ] GOLD - $10,000  

[  ] SILVER - $5,000   

[  ] BRONZE - $2,500

[  ] Other amount - $

PAYMENTS

Make all checks payable in US dollars to Digital Government Society of North America and send to:

USC-ISI

4676 Admiralty Way

Marina del Rey, CA 90292

Attn: Yigal Arens, DGSNA Treasurer