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Sponsor Detail Sign-up Information

Step 1	Non-Published Information: (this information is used to match with the Sponsorship Payment)
	Name:	Please keep me as an Anonymous Sponsor
	(or)
	Company:
	Phone:
	Email:
	Address:
	City:	State: Zip:

Step 2	Listing Information: (if we have questions, we will contact you via the information above)
	Business Name:
	Website:
	URL for Logo:
	Email:
	Phone:
	Services/Description:

| Health: 612-217-HEAL/612.217.4325 | info@psinergy.info | 821 Raymond Ave. Ste. 260, Saint Paul, MN |