2021 Educational Grant and Course Options Form Company Name* Contact Name* First Last Contact Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Grant Levels Diamond Level Support Platinum Level Support Gold Level Support Silver Level Support Bronze Level Support Diamond Level Support (Educational Grant: $75,000) • Acknowledged as Diamond Level Supporter -Two Scientific Panels of your choice -One keynote lecture of your choice -On-site with signage, slides and verbal recognition in session room -In pre-meeting promotional materials -On AHNS website and meeting app with hyperlink to company website -In AHNS journal, Archives of Otolaryngology • Receive Pre- and Post-Meeting Registration List *Requires a signed Letter of Agreement (LOA) in advance of the meeting for support to be acknowledged. Platinum Level Support (Educational Grant: $50,000) • Acknowledged as Supporter of -Two Scientific Panels of your choice • Acknowledged as Platinum Level Supporter -On-site with signage, slides and verbal recognition in session room -In pre-meeting promotional materials -On AHNS website and meeting app with hyperlink to company website -In AHNS journal, Archives of Otolaryngology • Receive Pre- and Post Meeting Registration List *Requires a signed Letter of Agreement (LOA) in advance of the meeting for support to be acknowledged. Gold Level Support (Educational Grand: $35,000) • Acknowledged as Supporter of -Two Proffered Paper Sessions of your choice -Poster Session • Acknowledged as Gold Level Supporter -On-site with signage, slides and verbal recognition in session room -In pre-meeting marketing materials -On AHNS website and meeting app with hyperlink to company website -In AHNS journal, Archives of Otolaryngology • Receive Pre- and Post-Meeting Registration List *Requires a signed Letter of Agreement (LOA) in advance of the meeting for support to be acknowledged.Silver Level Support (Educational Grand: $25,000) • Acknowledged as Supporter of -One Proffered Paper Session of your choice • Acknowledged as Silver Level Supporter -On-site with signage, slides and verbal recognition in session room -In pre-meeting marketing materials -On AHNS website and meeting app with hyperlink to company website -In AHNS journal, Archives of Otolaryngology • Receive Pre- and Post-Meeting Registration List *Requires a signed Letter of Agreement (LOA) in advance of the meeting for support to be acknowledged.Bronze Level Support (Educational Grant: $15,000) •Acknowledged as Bronze Level Supporter -On-site with signage, slides and verbal recognition in session room -In pre-meeting marketing materials -On AHNS website and meeting app with hyperlink to company website -In AHNS journal, Archives of Otolaryngology •Receive Pre- and Post-Meeting Registration List *Requires a signed Letter of Agreement (LOA) in advance of the meeting for support to be acknowledged. COURSESThe following specialized courses provide attendees with focused learning on in-demand topics. We seek the support of industry partners whose interests are aligned with the content presented. Support will be recognized on-site with signage, in the course via slides and recognition from the podium, in pre-meeting marketing materials, in the meeting app and on the AHNS website. Course outlines and faculty lists will be available September 2020. Course Options Saturday, July 18-½ Day Speech and Swallow Didactic Course Saturday, July 18-½ Day International Primer Course on Thyroid Cancer (didactic) Saturday, July 18-Robotics course ½ day didactic, ½ day hands-on lab (off-site) Sunday July 19-½ Day Advanced Practitioner Tract Total $0.00 Please note: Educational Grants & Course Options are to be payed by check only Please make checks payable to: American Head and Neck Society 11300 W. Olympic Blvd. Suite 600 Los Angeles, CA 90064 For more information, please contact Colleen Elkins at colleen@ahns.info.NameThis field is for validation purposes and should be left unchanged.