Company: ____________________________________________________________________________

Name: _______________________________________________________________________________

Title: _________________________________________________________________________________

Address:______________________________________________________________________________

Phone:_______________________________________________________________________________

Email:________________________________________________________________________________

Web Site: _____________________________________________________________________________

Select Sponsorship Level:

Availability will be on a first come first serve basis. Prior to mailing this form, you can reserve your spot immediately by contacting

Claude Miron at 613-220-1342 or [email protected].

Payment:

 Make cheque payable to: Ottawa Insurance Brokers Association

 Mail this form along with payment to: Catherine Morisset, Business Manager, OIBA, 136-2446 Bank Street, Suite 714, Ottawa, Ontario, K1V 1A8

Online: Credit card payment can be made by clicking on the Ecommerce link in the members area of our website.

Acceptance of Applicant

Upon acceptance of this application by the OIBA this application shall become a binding agreement between the sponsor and the OIBA The sponsor acknowledges that none of the sponsor investment is refundable unless otherwise stated in

the terms and Conditions to the OIBA Sponsorship Application.

Sponsor Signature: X______________________________________ Date:____________________

Printed Name: _____________________________________________________

Note that we will send you an official receipt within 30 days.

The Ottawa Insurance Brokers Association thanks you for your continued support!