LAA Exhibitor Registration FormDue: July 1st, 2014
Louisiana Academy of Audiology
P.O. Box 311, Ruston, LA 71273
EXHIBITOR REGISTRATION FORM
REGISTRATION DEADLINE: July 1, 2014
Instructions:
- ALL exhibitors MUST complete page 1 and page 7
- Platinum Booth Exhibitors complete page 2
- Gold Booth Exhibitors complete page 3
- Silver Booth Exhibitors complete page 4
- Basic Booth Exhibitors complete page 5
- Non-Profit Organization/University complete page 6
- Complete page 8 if paying by credit card
Upon completion of this form, please press the SUBMIT button and follow the instructions. Depending on your email server the form will either be automatically emailed or you may be required to save a copy and send via an email attachment. If paying by check, please mail the check to the address noted above after submitting the form.
EXHIBITOR INFORMATION:
Company Name: ______
Address: ______
Phone Number: ______
Email Address: ______
Contact Person(s): ______
BOOTH CONTACT PERSON: (Individual to contact for booth assignment, set-up times, etc.)
Name: ______Phone: ______
Email: ______
DIRECTORY LISTING FOR CONFERENCE PROGRAM – Three (3) line maximum
(Please list exactly as you would like it to appear in the conference program)
Example:LOUISIANA ACADEMY OF AUDIOLOGY, P.O. Box 311, Ruston, LA 71273
Website: Contact Steve Madix, President
(318) 257-2066,
PLATINUM LEVEL EXHIBITOR BOOTH
Includes 2 tables if wanted, please indicate “Yes” if a 2nd table is wanted. YES NO
Platinum Exhibitor Booth (5 representatives included)$3,000.00 + $ ______
Fee for Additional Representatives # ___ @ $125 per person (complete p. 7) $ ______
Electricity Needed (available upon request at no additional fee)
_____ Yes_____ No
TOTAL AMOUNT DUE $ ______
If paying by credit card, please complete page 8 – Credit Card Payment Information
THE FOLLOWING ARE INCLUDED FREE OF CHARGE, BUT IT IS THE RESPONSIBILITY OF THE EXHIBITOR TO MAKE SURE LAA IS PROVIDED THE INFORMATION
Please provide a print ready ¼ page (4” x 5.5” or 8” x 2.75”) full color advertisement for conference program via email to .
If registering prior to May 15th, please provide a 1/8 page (2” x 2.75”) full color advertisement for inclusion in conference mailings via email to .
Visit our website to plan out your website advertising for upcoming year.
If you would like to have an item included in attendee registration material, please indicate what you would like to include: ______.
2014 Louisiana Academy of Audiology Membership Information
Name: ______Email: ______
If you would like to provide an item for the silent auction, please provide contact information below and we will have a LAA representative contact them for specifics.
Contact: ______
EMAIL A COMPANY LOGO to (Please make sure that the logo is in jpg or pdf format in a minimum size of 4 x 6). This will be used on conference signage and on the Louisiana Academy of Audiology website as a link to your company site.
GOLD LEVEL EXHIBITOR BOOTH
Gold Exhibitor Booth 4 representatives included)$2,000.00 + $ ______
Fee for Additional Representatives # ___ @ $125 per person (complete p. 7) $ ______
Electricity Needed (available upon request at no additional fee)
_____ Yes_____ No
TOTAL AMOUNT DUE $ ______
If paying by credit card, please complete page 8 – Credit Card Payment Information
THE FOLLOWING ARE INCLUDED FREE OF CHARGE, BUT IT IS THE RESPONSIBILITY OF THE EXHIBITOR TO MAKE SURE LAA IS PROVIDED THE INFORMATION
Please provide a print ready ¼ page (4” x 5.5” or 8” x 2.75”) full color advertisement for conference program via email to .
If registering prior to May 15th, please provide a 1/8 page (2” x 2.75”) full color advertisement for inclusion in conference mailings via email to .
Visit our website to plan out your website advertising for upcoming year.
If you would like to have an item included in attendee registration material, please indicate what you would like to include: ______.
If you would like to provide an item for the silent auction, please provide contact information below and we will have a LAA representative contact them for specifics.
Contact: ______
EMAIL A COMPANY LOGO to (Please make sure that the logo is in jpg or pdf format in a minimum size of 4 x 6). This will be used on conference signage and on the Louisiana Academy of Audiology website as a link to your company site.
SILVER LEVEL EXHIBITOR BOOTH
Silver Exhibitor Booth (3 representatives included)$1,000.00 + $ ______
Fee for Additional Representatives # ___ @ $125 per person (complete p. 7) $ ______
Electricity Needed (available upon request at no additional fee)
_____ Yes_____ No
TOTAL AMOUNT DUE $ ______
If paying by credit card, please complete page 8 – Credit Card Payment Information
THE FOLLOWING ARE INCLUDED FREE OF CHARGE, BUT IT IS THE RESPONSIBILITY OF THE EXHIBITOR TO MAKE SURE LAA IS PROVIDED THE INFORMATION
Please provide a print ready ¼ page (4” x 5.5” or 8” x 2.75”) full color advertisement for conference program via email to .
If registering prior to May 15th, please provide a 1/8 page (2” x 2.75”) full color advertisement for inclusion in conference mailings via email to .
Visit our website to plan out your website advertising for upcoming year.
If you would like to have an item included in attendee registration material, please indicate what you would like to include: ______.
If you would like to provide an item for the silent auction, please provide contact information below and we will have a LAA representative contact them for specifics.
Contact: ______
EMAIL A COMPANY LOGO to (Please make sure that the logo is in jpg or pdf format in a minimum size of 4 x 6). This will be used on conference signage and on the Louisiana Academy of Audiology website as a link to your company site.
BASIC LEVEL EXHIBITOR BOOTH
Basic Exhibitor Booth (1 representative included)$500.00 + $ ______
Fee for Additional Representatives # ___ @ $125 per person (complete p. 7) $ ______
Fee for Electricity $85.00 _____ No _____ Yes
Interior Program Black & White Advertisement
(print ready copy must be provided via email to )
1/8 page (2” x 2.75”)$75.00 $ ______
¼ page (4” x 5.5”)$125.00 $ ______
½ page (8” x 5.5”)$250.00 $ ______
TOTAL AMOUNT DUE $ ______
If paying by credit card, please complete page 8 – Credit Card Payment Information
If purchasing a black & white program advertisement, please provide a print ready ad in the appropriate size via email to . (Please make sure that the advertisement is in jpg, pdf or doc format)
If you would like to provide an item for the silent auction, please provide contact information below and we will have a LAA representative contact them for specifics.
Contact: ______
EMAIL A COMPANY LOGO to (Please make sure that the logo is in jpg or pdf format in a minimum size of 4 x 6). This will be used on conference signage and on the Louisiana Academy of Audiology website as a link to your company site.
NON-PROFIT ORGANIZATION/UNIVERSITY BASIC EXHIBITOR BOOTH
Non-Profit Organization/University (1 representative included) $500.00 + $ ______
Fee for Additional Representatives # ___ @ $125 per person (complete p. 7) $ ______
Fee for Electricity $85.00 _____ No _____ Yes
Interior Program Black & White Advertisement
(print ready copy must be provided via email to )
1/8 page (2” x 2.75”)$75.00 $ ______
¼ page (4” x 5.5”)$125.00 $ ______
½ page (8” x 5.5”)$250.00 $ ______
TOTAL AMOUNT DUE $ ______
If paying by credit card, please complete page 8 – Credit Card Payment Information
If purchasing a black & white program advertisement, please provide a print ready ad in the appropriate size via email to . (Please make sure that the advertisement is in jpg, pdf or doc format)
If you would like to provide an item for the silent auction, please provide contact information below and we will have a LAA representative contact them for specifics.
Contact: ______
EMAIL A COMPANY LOGO to (Please make sure that the logo is in jpg or pdf format in a minimum size of 4 x 6). This will be used on conference signage and on the Louisiana Academy of Audiology website as a link to your company site.
REPRESENTATIVES ATTENDING CONFERENCE
Name(s) of Representatives Attending (Please include all requested information on each representative for continuing education purposes – Name, Title and Company will be printed on Conference Badge)
1)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
2)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
3)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
4)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
5)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
6)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
7)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
8)Name: ______Title: ______
Street: ______City: ______State: ____ Zip: ______
Email: ______AAA #: ______ASHA #: ______
CREDIT CARD PAYMENT INFORMATION
(FOR SECURITY REASONS, THIS IS INFORMATION WILL BE DESTROYED ONCE PAYMENT AUTHORIZATION IS COMPLETE, IT WILL NOT BE KEPT ON FILE)
Name on Card:______
Credit Card Number:______
Expiration Date: ______/______CVV Code: ______
Credit Card Billing Address: (Street Address)______
(City, State, Zip) ______
Email where receipt should be sent: ______
Amount to be Charged: $______
Signature: ______
IF PAYING BY CHECK, PLEASE MAIL PAYMENT TO:
LOUISIANA ACADEMY OF AUDIOLOGY
P.O. BOX 311
RUSTON, LA 71273
THE REGISTRATION FORM MAY STILL BE SUBMITTED VIA EMAIL TO: