Information Table Request Form
Northwest Urological Society
56th Annual Meeting
December 4-5, 2009 Bellevue Hyatt Regency
www.nwurologicalsociety.org
Number of 6 'x 18" Information tables @$1000 each. (Not an exhibit booth. Located outside the exhibit hall and does not include registration for company representative)
Name of Person requesting Information Table(s)
*
Company/Organization
Address:
City:
State:
AL
AK
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AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
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KS
KY
LA
ME
MD
MA
MI
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MS
MO
MT
NE
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NJ
NM
NY
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ND
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OK
OR
PA
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TX
UT
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VA
WA
WV
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Zip code:
Phone:
Fax:
E-mail:
*
Country:
Option 1
Option 2
Option 3
Special Requests:
Payment Option:
Credit Card
Check
Pay by Credit Card
Check off as many Information Tables as needed.
Information Table ($
1000
)
Information Table ($
1000
)
Information Table ($
1000
)
Information Table ($
1000
)
Information Table ($
1000
)
Total : $
0
Pay by Check
1) Submit this online form and mail your Check To: NWUS, 914 164th St. SE, Suite B-12 #145, Mill Creek, WA 98012
Check Amount
Check Number
mailed on