2019-2020 Signature Partnership Agreement 2019-2020 Signature Partnership Agreement EMERGENCY MEDICINE LEADERSHIP SUMMIT | NOVEMBER 12, 2019 The Conference Center at SeaTac 2020 SUMMIT TO SOUND | May 27-29 Bell Harbor Conference Center Company NameCompany Website Primary ContactPrimary Contact Name First Last Primary Contact TitlePrimary Contact Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact PhonePrimary Contact Email Primary Booth Representative Contact (This information will be published and distributed to attendees)Primary Booth Rep Contact Information The contact information for the Primary Booth Rep is the same as the Primary Contact Primary Booth Rep Name First Last Primary Booth Rep TitlePrimary Booth Rep Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Booth Rep PhonePrimary Booth Rep Email Representatives Staffing Your BoothRep #1 Name First Last Rep #2 Name First Last Rep #3 Name First Last Rep #4 Name First Last Exhibit InformationCompany TypeChoose all that apply Billing/Coding Services Cardiovascular Computer Software/Hardware Consulting Services Diagnostic Products/Services Documentation Services EDIS Educational Products/Services Emergency Medical Equipment Imaging/Ultrasound Equipment Insurance/Risk Management Market Research Ophthalmic Products Orthopedic Products Patient Monitoring Pharmaceuticals Recruiting Safety Specialty Products/Services Software Products Staffing/Management Telemedicine Product/Service to be displayedPlease indicate companies you desire NOT to be located adjacent to (i.e. competitor)Signature PartnershipPay in full now ($4500), or pay a 50% deposit now and be invoiced for $2250 in 2020.2019-2020 Signature Partnership AgreementSignature Partnership - $4500Signature Partnership Deposit - $2250Payment Type*Credit CardCheckInvoiceCheck NumberTOTAL $0.00 CREDIT CARD American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name INQUIRIES Contact Cailey Nickerson, Chapter Executive, at the Washington ACEP office at 206-956-3648 or send emails to admin@washingtonacep.org
