26th Annual Perinatal Partnership Conference - Exhibitor Registration

First Name *

Last Name *

Address *

Address (extra field)

City *

State

Zip

Email *

Phone Number *

Profession/Credentials *

Employer

Name of Exhibiting Organization *

Select Your Type of Vendor *

Bronze [$600.00]

Silver [$850.00]

Gold [$1,100.00]

Non-Profit [$100.00]

Retail $75 + 10% of sales (payment due the last day of exhibiting) [$75.00]

Number of Representatives *

Name(s) of Representatives *

Will provide a door prize *

No

Yes

Do you need any extra tables in addition to the one (1) provided? *

No

Yes

Every table exceeding the one provided is $45.00 each.

Extra Tables ($45 per table)

How many? quantity *

Will you need a standard electrical outlet (110v for an additional $50)? *

No, Thank You

Standard 120v Electrical Outlet

Will you need wireless internet? *

No, Thank You [$0.00]

Wireless Internet (additional $25) [$25.00]

Mid-Carolina AHEC