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L.� J 2016 IEDC EXCELLENCE IN ECONOMIC DEVELOPMENT AWARDS <br /> PAYMENT FORM <br /> �cuNOn„c n�v,tnrn„�r <br /> X.:OUNt H ,/� <br /> NAME: L //zr- <br /> TITLE:/0/10/17/c.- L'L?4Ol•v� <br /> //Af r <br /> ORGANIZATION: C i <br /> ADDRESS 1: J 30r s- <br /> Orb ri D P a TELEPHONE: /7‘.3, 4,35: 105/ <br /> ADDRESS 2: / FAX: <br /> CITY/STATE/ZIP: E l P„,J Mc) MA/5 30 EMAIL: /60./ 14„ triyJ, qDl/ <br /> I.General Purpose Print <br /> Brochure 13.Multi-Year ED <br /> 2.Special Purpose Print Brochure 14.Business Retention&Expansion-Single Event <br /> 3.General Purpose Print 15.Business Retention&Expansion-Program of 3 Years <br /> Promotion or More <br /> 4.Video/Multimedia Promotion _ 16.Entrepreneurship <br /> 5.Annual Report 17.Neighborhood Development <br /> 6.Paid Ad Campaign 18.Human Capital Program <br /> 7.Newsletter/Newspaper 19.Sustainable&Green Development <br /> 8.Magazine 20.Real Estate Redevelopment&Reuse <br /> 9.Special Event 21.Public-Private Partnerships <br /> 10.General Purpose Website 22.Partnerships with Educational Institutions <br /> 11.Special Purpose Website 23.Regionalism&Cross-Border Collaboration <br /> 12.New Media <br /> ,41iiimunity_population Size* Total: <br /> <25K 25-200K ❑200-500K ❑>500K <br /> *If projects from different population groups are submitted,please check all and explain on the back of this form. <br /> Entrants Dates Entry Fees Total Entries Submitted: ,lea. <br /> Early IEDC Members Feb 12-April 8 ❑ $110.00 / @$ Jf <br /> Early Non Members Feb 12-April 8 $190.00 of) <br /> Regular Members April 9-May 13 $165.00 Total Fees Enclosed: $ P/4. <br /> Regular Non Members April 9-May 13 ❑ $210.00 <br /> Entrants in Population Feb 12-May 13 g $110.00 <br /> Size <25,000 <br /> PAYMENT METHOD <br /> Payment must be received with applications.Nominations will not be considered until payment is rendered.Fee is in U.S. <br /> dollars.Please note that Entry Fees are non-refundable. <br /> O Check/Money Order# payable to IEDC is enclosed. <br /> Charge Credit Card: <br /> ❑VISA ❑ MASTERCARD ❑ AMEX <br /> Credit Card Number: <br /> Name on Ci ` I//. , fe Exp.Date: �. <br /> / K i Date: <br /> *INCLUDE ONE COPY OF THIS PAGE WITH YOUR APPLICATION(S). <br /> 5 <br />