SPONSOR / EXHIBITOR REGISTRATION FORM
13th Annual Pharmacology for Advanced Practice Nurses
September 30, 2016
HPR 809A
EXHIBITOR INFORMATION
Organization Name
Address
City
State
Zip
Contact Name
E-mail
Telephone Number
Fax Number
Names of persons attending the booth:
Parking attendant will be given the names provided above to access preferred exhibitor parking and unloading.
LOCATION: University of Southern Indiana, 8600 University Boulevard, Evansville, IN 47712
University Center, Carter Hall
LEVEL
LUNCHEON SPONSOR (2)
BREAK SPONSOR (3)
EXHIBITOR
EXHIBIT:
FEE
$750
$500
$250
Each exhibit space is one 6' table with a white linen table covering.
SPECIAL NOTES:
ELECTRICITY _____YES ______NO (Electricity requests must be made in advance.)
OTHER _______________________________________________________________
*Please note that outside food may not be brought in and distributed at your exhibit table; wrapped candy is
acceptable.
DEADLINE: Return sponsor / exhibitor registration form by 09/09/16.
METHOD OF PAYMENT (USI Tax ID number: 351308176)
Check (Make checks payable to: USI)
Credit Card: We accept VISA, MASTERCARD, AMEX AND DISCOVER
Card #:
Exp. Date: ____/____
Credit Card Billing Zip Code:
Security Code: (on back of card)
Name on card:
Billing Address: (if different from address given above):
TO REGISTER: RETURN to Jennifer Hertel at jshertel@usi.edu or fax to 812/465-7061