Venous Symposium - Exhibitor Application

Date: 02/12/2012

Organization (Please use proper case, this will appear on your name tag!):

Main Contact First Name:

Main Contact Last Name:

Daytime Phone (include area code):

Email (COMPLETE Internet Email Address!! jdoe@someplace.com):

Verify Email:

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Mailing Address (Should match your billing address on your credit card statement):
Street Address:
Address cont.:
Address cont.:
City:
State: Postal/Zip Code:
Country:

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Representatives:
Please include all attending representatives' names & complete phone numbers (1 per line):
(sample: Jane Doe - 631-555-1212)

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1st Venous Symposium - Exhibitor Application: Prevention & Treatment of VTE
March 27, 2010

Exhibit Fees (Pick only ONE):
Exhibit time will be available 8:00am - 5:00pm in the registration and break area, separate from the lecture hall.

1. 6' x 6' space, includes 1 table & 2 chairs: $1,000
2. 6' x 12' space, includes 2 tables, 4 chairs, an electrical outlet & Internet access. (Please indicate any special power requirements): $1,500
3. 6' x 18' space, includes 3 tables, 4 chairs, an electrical outlet, Internet access & company logo in conference program. (Please indicate any special power requirements): $2,500

6' x 6'
6' x 12'
6' x 18'

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Form Developed by Last Modified 02/12/2012 07:35:30 AM