Please fill out the following: Name: ___________________________________ Email: __________________________________________ Name or Company/Store (optional):____________________________________________________ Address:______________________________________________________________ Apt#:________________ City:_________________________ State:________ Zip:_____________Phone#:______________________ Please select one of the following: ☐ Premiere Package: $1500-Sponsors 3 full dentures & 2 partial dentures. Large in color company logo on race shirts; complimentary team of up to 20 participants with race shirts; priority information table day of the race; personalized website sponsor page; Facebook listing & company logo on all advertising material ☐ Diamond Package: $1000-Sponsors 2 full dentures & 1 partial denture. Large in color company logo on race shirts; complimentary team of up to 15 participants with race shirts; Facebook listing; logo display on race website ☐ Platinum Package: $700-Sponsors 2 full denture cases. Small black & white logo on race shirts; complimentary team of up to 10 participants with race shirts; Medium company logo on race website ☐ Gold Package: $350-Sponsors 1 full denture case. Small print of company name on race shirts; listed on race website; complimentary registration for up to 5 participants. ☐Other: Donation Amount $___________________ For more information, please contact Adria Miner, Event Coordinator at: ignitesmiles@gmail.com Please make all checks or money orders payable to “ASDA at UT Arlington” *Would you like to be Anonymous? Yes/No *This donation is ☐ In memory of______________________ ☐ In honor of _______________________ Thank you for your support!