Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4444 Special Populations Exhibitor Registration Form 2017 ACCP Annual Meeting EXHIBIT COMPANY ___________________________________________________________________________ ADDRESS ________________________________________________________________________________ CITY _______________________________ STATE __________ COUNTRY _______________________ ZIP ______________ CONTACT PERSON* ___________________________________________________________________________ *Person responsible for disseminating Exhibit information from ACCP. PHONE _____________________ CELL PHONE _____________________ EMAIL ____________________________________ EXHIBIT FEE (Includes Two Exhibit Personnel): $2,250 ____________ ADDITIONAL EXHIBITOR FEE: $250 each ____________ EXHIBIT FEE (Includes Two Exhibit Personnel PLUS Limit of One Full Registration to the Annual Meeting**): $2,750 _____________ BOOTH SPACE CHOICES #1 _______________ #2 _______________ #3 _______________ A/V Requirements? (Please specify) Costs incurred to provide this equipment will be billed to the Exhibitor. ______________________________________________________________________________________________________ METHOD OF PAYMENT (check one): ❑ Check*** (Payable to ACCP in US Dollars drawn on a US Bank) ❑ VISA ❑ American Express ❑ MasterCard ❑ Bank Transfer Cardholder name (print): ________________________________________________________________________ Card number: ___________________________________________________ Expiration date: __________/________________ Authorized signature: _______________________________________________________________________________ Amount in US Dollars authorized to charge: _______________________ For 2017 ACCP ANNUAL MEETING EXHIBIT FEE Complimentary Exhibit Staff Person #1: Name ____________________________ Cell Phone ______________________ Email _______________________________________________________________________________________ Degree(s) to be displayed on attendee badge ____________________________________________________________ Complimentary Exhibit Staff Person #2: Name ____________________________ Cell Phone __________________ Email _______________________________________________________________________________________ Degree(s) to be displayed on attendee badge ____________________________________________________________ Full Registrant designated to attend 3-Day Annual Meeting** (if applicable and purchased above) Name ____________________________________________ Cell Phone _________________________ Email _______________________________________________________________________________________ Degree(s) to be displayed on attendee badge ____________________________________________________________ **Please note that Continuing Education credit cannot be earned through this mode of registration; payment is required to earn credit, as enforced by the accreditation guidelines. Additional ($250 Fee) Exhibit Staff Person #3: Name ______________________________ Cell Phone _____________ Email _______________________________________________________________________________________ Degree(s) to be displayed on attendee badge ____________________________________________________________ Additional ($250 Fee) Exhibit Staff Person #4: Name ______________________________ Cell Phone ______________ Email _______________________________________________________________________________________ Degree(s) to be displayed on attendee badge ____________________________________________________________ COPY THIS PAGE AS REQUIRED FOR ADDITIONAL EXHIBITOR PERSONNEL. DESCRIPTION OF COMPANY (50 words or less) must be included with payment. Additionally, please send your company URL and high-resolution logo in EPS, JPEG, PNG, or GIF format to Exhibit@ACCP1.org at the time of Exhibitor registration. ***Checks should be mailed to ACCP, PO Box 1758, Ashburn, VA 20146-1758 ACCP’s Tax ID number is 22-1950891 Exhibit fee includes 10’ booth space, one 6’ table, two chairs and a wastebasket.