We would like to be an Exhibitor:   

 For Profit Organization - $450 for one full exhibitor registration (commercial/government/state/county agencies)          
 Non-Profit Organization - $300 for one full exhibitor registration (academic/other non-profit (501c3 status)
 We would like to include a second person to help with exhibit for $150 (JCH presenters are excluded) 
 I am contributing as a sponsor for JCH under the category of Prime, Major, Key, or Sponsor and am receiving a complementary exhibit space.

We would like to sponsor a break: $250 per break.  We would like to sponsor a break on:

Monday morning         Monday afternoon         Tuesday morning       Tuesday afternoon     Wednesday morning

We would like to make a financial contribution:  We would like to donate $ towards the conference.

We would like to donate materials:       Pens, pencils, markers, note pads, etc.           Other

Equipment, supplies, processes, services, or information to be exhibited:

Indicate the name(s) of those who will be exhibiting at the conference (for name badge):

  First Name                                                  MI           Last Name                             Degree(s)                           Title/Position

  First Name                                                 MI            Last Name                             Degree(s)                           Title/Position          

   Agency Name and Mailing Address 
       Phone:        (Example: 206-555-1212)
            Fax:      
      E-Mail:      
      
   
  Federal Identification Number (TIN)     
     Vegetarian meals (1st Exhibitor)      Presenter/Panelist? (1st Exhibitor)
                                                                                                                 Vegetarian meals (2nd Exhibitor)     

  
 Comments:         

  Payment for exhibitor registration will be made by:   Purchase order from my agency            Check from my agency               Personal Check    

  Credit Card Payment*  Type of credit card:  American Express        Master Card         Visa

  Name of the Card Holder (necessary to properly match payment with registration(s):

 Paying by check,  money order, or purchase order: Please print out this form before submitting it below.  Mail or fax in a copy with purchase order or payment. Payment will be matched up with the electronic registration received over the site.

 Paying by credit card: *The link for processing on-line credit card payments is located on the confirmation page which will come up after you click on the submit button below.  Please print this completed form and click on submit.  Please Note: If you are paying for more than one Exhibit by credit card and/or the registrant's name is different from that of the credit card holder, you may be asked to provide a list of exhibitor names being paid by the credit card - especially if you go on-line more than once to process multiple payments with the same card.  The billing address must be an identical match the billing address on the credit card statement or else the card will not go through.  WSPHA is charged for every attempt to process credit cards.  If it does not go through the first time, please contact Kathy Kondakjian.   Please e-mail kathy@wspha.org if you have any questions or call 425-337-5717.