CEP EVENT REQUEST

Form

Community Engagement Professional Information

Community Engagement Professional Name *

Community Engagement Professional Email *

Department *

Jose Ramirez

Eva Blandino (TESTING)

Martin Visconti

Request Date * +

Event Information

Event Name *

Expected Attendees:
How many attendees are you expecting?

Event Purpose *

Lead Acquisition

Retention

Education

Other Other

Event Communication Information

Event Date * +

RSVP by Date * +

Start Time *

End Time *

Venue *

If you chose "other" please enter the venue here

Out-of-clinic Address

Street Address *

Address Line 2

City *

State

Zip Code

Event Contact

Event Contact Name *

Event Contact Phone Number *

Event Contact Email *

Sponsor/Partner

Event Sponsors/Partner
Please send the sponsor's logo in Hi-Def format to events@infinitemktg.com

Event Sponsors/Partner Contact Information for approvals
If the event has a partner or sponsor, please complete the fields below

Sponsor's Contact Name

Sponsor's Contact Phone

Sponsor's Contact Email

Event Promotion (Allow 5 business days for approval print and delivery.)

Flyers

	Set of 100 ($275) Flyers
	Set of 350 ($275) Flyers
	Set of 500 ($350) Flyers
	Set of 1000 ($475) Flyers

Postcards

	Set of 500 ($265) Postcards
	Set of 1000 ($295) Postcards

Door Hangers

	Set of 100 ($250) Door Hang
	Set of 500 ($295) Door Hang
	Set of 1000 ($375) Door Hang

Direct Mailing 🛈

	Set of 500 ($750) Direct Mail
	Set of 1000 ($1100) Direct Mail

Posters

	Single poster ($35)
	Set of 2 posters ($60)
	Set of 4 posters ($195)

Current Total:

$0.00

For Direct Mailing, please email the recipient list in CSV or Excel format to events@infinitemktg.com.
LIST MUST CONTAIN FIRST NAME, LAST NAME, STREET ADDRESS, CITY, STATE AND ZIP CODE.

Communication Template

Speaker/guest/physician (if applicable)

Event
Topic

Speaker/Guest/Physician Fee
Enter the speaker/guest/physician fee to speak or present at this event (for events that include them).

Current Total:

$0.00

Confirm Subtotal (Event Promo) *

Incentives

TV Raffle

$15.00 gift card

$10.00 gift card

Health Assessment

Collateral

Tri-fold Brochure

	Set of 250 ($200) Try-fold
	Set of 500 ($250) Try-fold
	Set of 1000 ($300) Try-fold

Large bi-fold brochure

	Set of 250 ($200) Bi-fold
	Set of 500 ($250) Bi-fold
	Set of 1000 ($300) Bi-fold

CWC Booklet

	Set of 250 ($200) Booklets
	Set of 500 ($250) Booklets
	Set of 1000 ($300) Booklets

Open House Invitation Flyer

	Set of 250 ($200) Open House
	Set of 500 ($250) Open House
	Set of 1000 ($300) Open House

EliteHealth Newspaper

	Set of 250 ($200) Newspaper
	Set of 500 ($250) Newspaper
	Set of 1000 ($300) Newspaper

Open House Date +

Future Event Flyer

	Set of 250 ($200) Future
	Set of 500 ($250) Future
	Set of 1000 ($300) Future

Physician’s Bio Flyer

	Set of 250 ($200) Physician’s Bio
	Set of 500 ($250) Physician’s Bio
	Set of 1000 ($300) Physician’s Bio

Physician's Name

Current Total:

$0.00

Confirm Subtotal (Collateral Promo) *

Event Logistics

Services & Talent/Speaker

TALENT/DJ/TRAINER
Enter cost

Snacks
Enter cost

Transportation
Enter cost

Other
Enter cost

Event Logistics Total (Services, Talent/Speaker):

$0.00

Confirm Subtotal (Logistics) *

Incentives

TIER 1

Promo Items

	Set of 25 Pen ($12.50)
	Set of 25 Glass cleaning cloths ($37.50)
	Set of 25 Sanitizer ($43.75)
	Set of 25 Nail Files ($25)
	Set of 25 Stress Ball ($38)
	Set of 25 ID wallets ($56.25)

Promo Items

	Set of 25 First Aid Pouch ($56.25)
	Set of 25 Round Mirror ($38.75)
	Set of 25 Jar Opener ($43.75)
	Set of 25 Whistling Keychain ($68.75)

TIER 2

Promo Items

	Set of 25 First Aid Kit ($123.75)
	Set of 25 Insulated lunch bag ($73.75)
	Set of 25 Water bottle cover ($62.50)
	Set of 25 Magnifier with light ($87.50)

Promo Items

	Set of 25 Car Shade ($187.50)
	Set of 25 Rain Poncho ($75)
	Set of 25 Manicure Set ($75.00)
	Set of 25 Pill Holder Big ($75.00)

TIER 3 To be used as a raffle or a special gift for Agent/Broker/Property Manager

Promo Items

	Set of 25 Umbrella ($375)
	Set of 25 Portfolio with Pen ($350)
	Set of 25 Insulated Steel Mug ($250)

Current Total:

$0.00

Confirm Subtotal (Incentives) FINAL TOTAL *

Miscellaneous CEP Comments

Next Event Information

Next Event Date * +

Next Event Venue *

If you chose "other" please enter the next event venue here

Comments about the next event. *

Social (bingo, dance, games)	Exercise class Doctor Talk
Open House	Social Services
Health Fair	Medicare 101 Agent/sales networking
Class (Indicate which class) Class (Indicate which class)

CEP EVENT REQUEST Form