2016-2017 Signature Partnership Agreement


EMERGENCY MEDICINE LEADERSHIP SUMMIT | NOVEMBER 2, 2016 | THE CONFERENCE CENTER AT SEATAC
2017 SUMMIT TO SOUND | APRIL 27-28, 2017 | BELL HARBOR CONFERENCE CENTER, SEATTLE

Company Name:
Company Website:

Primary Contact

Primary Contact Name:
Primary Contact Title:
Primary Contact Address:
Primary Contact Phone:
-
Primary Contact E-mail:*

Primary Booth Representative Contact

(This information will be published and distributed to attendees)

Primary Booth Rep Name:
Primary Booth Rep Title:
Primary Booth Rep Address:
Primary Booth Rep Phone:
-
Primary Booth Rep E-mail:

Representatives Staffing Your Booth

Rep #1 Name:
Rep #2 Name:
Rep #3 Name:
Rep #4 Name:

Exhibit Information

Product/Service to be displayed:
Please indicate companies you desire NOT to be located adjacent to (i.e. competitor):

Signature Partnership

Pay in full now ($4500), or pay a 50% deposit now and be invoiced for $2250 in 2017.

2016-2017 Signature Partnership:
Total:
Please verify:

Upon completing the form and clicking "submit," you will be directed to PayPal to make the Signature Partnership Agreement payment.

INQUIRIES
Contact Pauline Proulx, Chapter Executive, at the Washington ACEP office at 206-956-3648 or send emails to plp@wsma.org