Manufacturers' Registration Form

Send This Form and Check to:
Mid-America Conference on Hearing
PO Box 1164, Danville KY 40423-1164

       
      . .Customer Information
      Company:
      Name: 
      Email: 
      Phone: 
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      Manufacturer's Registration
      Details: Number of Skirted Table(s)
      Early Registration (by May 19) - $995 each
      Regular Registration (after May 19) - $1400 each
      Trash Can Required Yes No
      Number of Rep(s) Attending
      Names(s) (required for CEU only)
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      Reps Meeting & Luncheon
      Thursday, June 26, 2008
      Details: Number of Rep(s) Attending - No Cost
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      Payment Information
      Payment Type: MC Visa Discover 
      Check Check Number
      Amount: Total $
      Credit Card Number:
      Expiration Date: Month (MM)    Year (YY) 
      Name on Card:
      Billing Address:
      City, State, Zip: , 
      Signature:
      (for credit card only)
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