Exhibitor Request Form
Northwest Urological Society
56th Annual Meeting
December 4-5, 2009 Bellevue Hyatt Regency
Number of 8x10 Exhibit Booths @$2000 each (Includes registration for up to 3 company representatives)
Name of Point person for the Exhibit(s)
*
Company
Address:
City:
State:
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code:
Phone:
Fax:
E-mail:
*
Names of Representatives staffing exhibit booth: (email information is REQUIRED)
Rep. Name 01
Rep. 01 email
Rep. Name 02
Rep.02 email
Rep. Name 03
Rep. 03 email
NOTE: Additional representatives will need to pay an $85 Registration Fee to help cover the expense of meals provided.
Special Requests:
Number of Booths Needed:
Check off as many Exhibit Booths as Needed. (8x10 booths, includes registration for up to 3 company representatives.)
Exhibit Booth (8x10) ($
2000
)
Exhibit Booth (8x10) ($
2000
)
Exhibit Booth (8x10) ($
2000
)
Exhibit Booth (8x10) ($
2000
)
Exhibit Booth (8x10) ($
2000
)
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