Exhibit Form
RESERVATION FOR EXHIBITS
The Way Forward…Tried and True and Something New
MSHA Annual Conference ~ March 22-24, 2012
The Radisson Plaza Hotel, Kalamazoo, Michigan 49007
Company Name_________________________________ Company Representative____________________________
Address_______________________________________ Local Address (if necessary)__________________________
City & State_______________________________Zip_______City & State_______________________ Zip___________
Phone: Day: ___________________________ Evening:_______________________ FAX:____________________
Email address:________________________________ Donation for Raffle:___________________________________
Please indicate the number of tables requested. Tables are 6 feet in length, skirted, linen table covering, 2 chairs. Electrical outlets are an additional $30. 2 Persons per exhibit table. Your fee covers all three days.
□ 1 Table, no elec: $350 □ 1 Table, with elec: $380 □ 2 Tables, no elec: $550 □ 2 Tables, with elec: $580
□ 3 Tables, no elec: $700 □ 3 Tables, with elec: $730 □ 4 Tables, no elec: $800 □ 4 Tables, with elec: $830
□ 1 Unattended table for display of products or catalogs: $150
□ Presentation/Seminar during conference: $300 Session length: 3 hours 2 hours 1 hour
1. Which days will you be there? □ Thursday □ Friday □ Saturday
2. Do you require an electrical outlet? □ Yes □ No (See above for price differentiation)
3. Any other special requests?_______________________________________________________________________
(Will accommodate if possible)
4. Please indicate your choice of luncheons: □Friday Awards Lunch $25 ___Regular ___Vegetarian Total: $_______
□ Sat PSC Forum Lunch $25 □ Saturday Med SLP Forum Lunch $25 ___Regular ___Vegetarian Total: $_______
Are you interested in any of our sponsoring choices at this conference? (See Sponsorship Opportunities) □ Yes
Please return this form with either your check, made payable to MSHA, or charge option (see below) by February 22, 2012. Exhibitors will be accepted on a first-come, first-served basis. Thank you! Hope to see you in Kalamazoo!
Nancy Nelson, M.A., CCC-A
Professional Hearing Consultants, East Lansing
Julie Fisk, M.A., CCC-SLP
Ingham Regional Medical Center, Lansing
Payment Options:
Amount: $___________________ Check enclosed or:
VISA Card MasterCard Discover Card #_______________________________________________________
Expiration Date:_____________________ Card Holder Name:_____________________________________________
Authorized Signature:_______________________________________________________________________________
MSHA
790 W. Lake Lansing Rd., Suite 500-A East Lansing, Michigan 48823
Phone: 517/332-5691 FAX: 517/332-5870 Email: msha@att.net Website:www.michiganspeechhearing.org