Vendor Registration Form Company/Organization Name * Name of Representative(s) * Street Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, DCWest VirginiaWisconsinWyoming–U.S. Territories–American SamoaFederated States of MicronesiaGuamMidway IslandsPuerto RicoU.S. Virgin Islands Zip Code * Phone * E-mail Address: * Will you require hotel accomodations? $119 per night Wednesday October 28, 2015 $119 per nightThursday October 29, 2015 $119 per nightFriday October 30, 2015 $119 per nightSaturday October 31, 2015 $119 per night Would you like an ad in our program? Full Page Ad $250Half Page Ad $150Quarter page Ad $100Business Card Ad $50 Will you sponsor the convention to help offset operational costs? Platinum Sponsorship $1000Gold Sponsorship $750Silver Sponsorship $500 Number of Tables $150 $50 for NonProfit organizations Will you require an outlet * Require an Electrical OutletDon’t Require an Electrical Outlet Will you be sending a door prize/materials for the take away bags? If so please describe Continental Breakfast $18 Saturday Luncheon $38 Chicken Marsala with Yellow Rice and Medley of Seasonal Vegetables $38Penne Pasta with Asparagus, Sherry Butter $38 Banquet Dinner $55 Chicken Breast with Vidalia Onion, Balsamic Reduction served with Oven Roasted Potatoes and Broccoli and Carrots $55Pork Medallion with Pineapple Mango Salsa with Oven Roasted Potatoes and Broccoli and Carrots $55Eggplant rollatini $55 Reasonable Accomodations Method of Payment * Mailed Regular CheckPayPal Total amount to be paid * * Required
