"Sweet New Adventures"

Exhibitor Registration Form

1.  Complete the demographic information below.

* Required information

* Company:
	Are you a 2010 PHIMA Corporate Sponsor?  Yes   No  Learn more
Contact Information
* First Name:
* Last Name:
* Address:
Address:
* City:
* State:	Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International
* Zip Code:
* Phone:
Fax:
* E-mail:
Website:
Attendance
*	Select One 0 1 2 3 4 5 6 7 8 9 10 How many representatives will be in attendance?
	Name Badges
	Please list the participants that will require name badges.
	First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name     First Name Last Name
2.  Booth Selection and Special Events
Booth	View the Floor Plan What are your choices for preferred booth number?  Premiere Booths are denoted with an asterisk. Booths are sold out
*	Packages -  Items included in the booth packages
	Basic Single Booth (before 2/1/10 $650; after 2/1/10 $775 )
	Premier Single Booth (before 2/1/10 $1200; after 2/1/10 $1,375)
	Double Premier Booth (before 2/1/10 $1500; after 2/1/10 $1,675)
	If you have any questions please call Lorri Luciano at 610-554-7928  or lmclinden@phima.org. Registrants will receive further information once payment is received.
Utilities Needed for Booth
*	Electricity needed?                          Yes  No
*	Internet access needed ?                 Yes  No
Tuesday Breakfast with Vendors
*	To assist PHIMA with planning for this event, please indicate how many representatives will be attending this Tuesday event.  Additional tickets can be purchased for this event. Select One 0 1 2 3 4 5 6 7 8 9 10 Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included
Tuesday Vendor Appreciation Luncheon
*	To assist PHIMA with planning for this event, please indicate how additional tickets will be needed for this Tuesday luncheon.  Additional tickets can be purchased for this event. Select One 0 1 2 3 4 5 6 7 8 9 10 Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included
Tuesday Networking with Peers Reception
*	To assist PHIMA with planning for this event, please indicate how many representatives will be attending this Tuesday evening event. Additional tickets can be purchased for this event. Select One 0 1 2 3 4 5 6 7 8 9 10 Basic Single Booth - 2 Tickets Included Premiere Single Booth - 3 Tickets Included Double Premiere Booth- 4 Tickets Included
*3. Sponsorships
If you are interested sponsoring an event or item for the meeting, please make your selection below.  To select more than one, select your Ctrl key and click on your selections.   We are not interested in sponsorship at this time Monday Afternoon Break (SOLD) President’s Reception (Monday) President's Reception Entertainment (SOLD) Tuesday Breakfast Networking with Peers Reception (Tuesday) Wednesday Luncheon Keynote Speaker Product Donation – Name Tag Neck Wallets (with your Company Logo) PHIMA Scholarship Donation Product Donation – Binder/Bag (with your Company Logo) Speaker Other If you have any questions please call Lorri Luciano at 610-554-7928 or lmclinden@phima.org.
Sponsorship Opportunity Cost Benefit Monday Afternoon Break $500 Company sign & literature will be displayed in the break area and noted in the Program Book President’s Reception (Monday) $2,500 Company sign & literature will be displayed in the break area and noted in the Program Book. President's Reception Entertainment $500 Company sign & literature will be displayed in the area and noted in the Program Book Tuesday Breakfast $1,000 Company sign & literature will be displayed in the break area and noted in the Program Book. Networking with Peers Reception (Tuesday) $1,500 Company sign & literature will be displayed in the break area and noted in the Program Book. Wednesday Luncheon $1500 Company sign & literature will be displayed in the breakfast area and noted in the Program Book. Keynote Speaker (Monday or Tuesday) $1,500 Company sign & literature will be displayed at the break area and noted in the Program Book Product Donation – Name Tag Neck Wallets (with your Company Logo) $1,500 Company’s donation will be noted in the Program Book. PHIMA Scholarship Donation   $500 per student Company’s donation will be noted in the Program Book and a company representative will sit with the student at a special table at the Luncheon. A company representative will present the award. Product Donation – Binder/Bag (with your Company Logo)  $2500 full sponsorship or $1500 partial Company donation will be noted in the Program Book. Speaker   $300 Allows you to introduce speaker, provide literature in education session and have your name or logo posted in meeting room. Other   Donations for events your company does not want to fully sponsor (i.e. President reception entertainment, bags, etc).
4. PHIMA Website and Program Vendor Information
The information completed in this section will be published in the PHIMA vendor book as well as published on the PHIMA website. We will not be publishing logos or ads this year.
	*Contact Name Phone Number Email Address
*	Company Description
	Enter a brief company description.

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5.  Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the cancellation policy, insufficient check funds policy, and exhibitor agreement.

*       Select Below Yes, I agree to the terms and conditions.

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6. Questions or Comments

Do you have a question or comment?  Please enter below and we will contact you.

Payment options include: Check or credit card