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Application for Exhibit Space

Exhibit Request Deadline: August 1, 2017

Company Name (As you wish it to appear in program) Direct Correspondence to

Address

City

State/Province

Zip

Telephone Fax

Description of Product/Service: (50 words or less) email as an attachment (.doc or .pdf) a description of company and/or products on display as you would like it to appear in the marketing handout. Exhibit Space Options

Exhibit Payment

Corporate (Non-Member)

Table @ $2,500 each

Corporate Alliance Member

Table @ $2,000 each

Foundation Alliance Member

Table @ $250 each

Non-Profit (Non-Member)

Table @ $500 each

US$ US$

US$ US$

YES we would like to explore additional sponsorship opportunities

(payment must accompany application form) Checks payable to Global Genes (US $ only) Check No.

VISA

MasterCard

AMEX

Card No. Exp.

3 or 4 digit security code

Name as it appears on card Authorized signature

Email form to: Ashlei Brittany, exhibitors@globalgenes.org Limit of 2 representatives per exhibit. Each exhibit will receive one (1) complimentary Exhibitor Full Meeting badge.


2017 Global Genes Patient Advocacy Summit Exhibitor Application