2016 Entrepreneurial Insurance Symposium EIS Brochure | Page 17

Exhibitor Opportunities NETWORKING MALL EXHIBITOR AGREEMENT & SELECTION FORM - PART I Thank you in advance for participating in the 2016 Entrepreneurial Insurance Symposium! MarketScout will send each exhibitor a signed copy of this contract acknowledging acceptance and specific sponsorship benefits according to the prior pages of this document. _________ Exhibit Booth $1,600 _________ Total Attendee Registration(s) ($420/attendee) _________ CIC/CRM Update or Requesting CE Credit-Registrations ($420/attendee) Grand Total Due for Exhibitors Please make checks payable to MarketScout. $ ________________________________ Company Name: __________________________________________________________________________________ Contact Name: ________________________________ Title/Position: ____________________________________ Phone: ________________________________________ Email: ____________________________________________ Method of Payment: American Express MasterCard Visa Check #:______________ Credit Card #: _________________________________ Exp. Date (MM/YY): ____________ CVC #: ___________ Credit Card Billing Address: _______________________________________________________________________ City: ________________________________________ State: ______________________ Zip: ____________________ Name on Card (Please Print): ______________________________________________________________________ Signature (Required): ____________________________________________ Date: ___________________________ Please send completed Exhibitor Agreement & Selection Forms Part I & II to Diahann Doyen by fax at [phone] or email at [email protected]. You will receive confirmation once your sponsorship has been approved. Sponsorships are assigned on a first-come, first-served basis and are non-refundable. Tel: [phone] Email: [email protected] www.eInsuranceSymposium.com