2018 Annual Meeting Exhibitor Registration ANNUAL SCIENTIFIC MEETING NOVEMBER 2 – 3, 2018 BELL HARBOR INTERNATIONAL CONFERENCE CENTER SEATTLE, WA Company Information Company Name Company Website Primary Contact InformationPrimary Contact Name First Last Primary Contact Title Primary Contact Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Contact PhonePrimary Contact Email* Primary Booth Representative Contact(This information will be published and distributed to attendees)Primary Booth Representative Information is the same as Primary Contact Primary Booth Rep Name First Last Primary Booth Rep Title Primary Booth Rep Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Booth Rep PhonePrimary Booth Rep Email Representatives Staffing Your BoothRep #1 Name First Last Rep #2 Name First Last Two booth representatives are included with your exhibit package. Extra booth reps are $150 each.Rep #3 Name First Last Rep #4 Name First Last Exhibit Space InformationExhibit space will be assigned based on level of sponsorship, exhibit location purchased, followed by first come basis.Product/Service to be DisplayedPlease indicate companies, if any, you desire NOT to be located adjacent to (i.e. competitor)Exhibitor RegistrationExhibit RatePlease select your exhibit packageTable Top Exhibit - $1350.00Optional - Additional Booth RepresentativesTwo booth representatives are included with your exhibit package. Extra booth reps are $150 each.Select additional number of repsOne additional rep - $150.00Two additional reps - $300.00TOTAL $0.00 CREDIT CARD American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name There is a $250 fee for cancellations received on or before October 7. No refunds for cancellations received after October 7, 2018. INQUIRIES Phone: (206) 956-3652 or email admin@washingtonacp.org TAX ID# 51-0222670
