th
Name of business: _______________________________________________________
Name of recruiter(s): _____________________________________________________
Address: ______________________________________________________________
______________________________________________________________________
Phone:__________________ Fax:_______________________
Email:_____________________
Discipline recruiting (circle all that apply)
PT OT SLP
Amount Paid-$200.00/booth (circle one) Check
$250.00/booth After March 22, 2012
Money Order
$_____________ # of booths __________ Special requirements:
______ electrical outlet (first requested, limited number available)
______ number of parking passes needed
Please make check or money order payable to: Eastern Washington University
EWU Tax ID number 91-6000624
Please mail form and payment to:
Eastern Washington University
Department of Physical Therapy
Attn: Cindy Crago
Box T 310 N. Riverpoint Blvd.
Spokane, WA 99202-1675