PNWD 85th Annual Scientific Conference Exhibitor Registration Pacific Northwest Dermatological 85th Annual Scientific Conference July 20-22, 2018 The Coeur d'Alene Coeur d'Alene, Idaho Please complete the form below to exhibit at the PNWD 85th Annual Scientific Conference Or Maximize Your Presence … Take Advantage of these Exclusive Support Opportunities! PNWD 85th Annual Scientific Conference Meeting Packages Include The Following: Conference Supporters Receive… Verbal recognition at the podium Complimentary exhibit space Print acknowledgement of support on posters, the PNWD e-syllabus and WSDA website Electronic list of attendees prior to the conference to promote visits to your booth Four vendor ticket packages, with sponsorship ribbons Access to the Saturday Night Dinner Please complete the form below to exhibit at the PNWD 85th Annual Scientific Conference Or Maximize Your Presence … Take Advantage of these Exclusive Support Opportunities! PNWD 85th Annual Scientific Conference Meeting Packages Include The Following: EXCLUSIVE SUPPORTER OPPORTUNITIES AVAILABLE: GOLD SUPPORTER - $7,000 SATURDAY FAMILY DINNER Have your company name be seen by supporting the dinner or reception. SILVER SUPPORTER $5,000 (each) BREAKFAST – Saturday Morning BREAKFAST – Sunday Morning Have your company name be seen by supporting a breakfast. BRONZE SUPPORTER $4,000 (each) COFFEE BREAK – Friday COFFEE BREAK – Saturday COFFEE BREAK – Sunday Have your company name be seen by supporting a coffee break. Company NameWebsite Primary Contact InformationPrimary Contact Name First Last Primary Contact TitlePrimary Contact Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Contact PhonePrimary Contact Email* Primary Booth Representative Contact(This information will be published and distributed to attendees)Primary Booth Representative Information is the same as Primary Contact Primary Booth Rep Name First Last Primary Booth Rep TitlePrimary Booth Rep Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Booth Rep PhonePrimary Booth Rep Email Representatives Staffing Your BoothRep # 1 Name First Last Rep #2 Name First Last Two booth representatives are included with your exhibit package. Extra booth reps are $250 each.Rep #3 Name First Last Rep #4 Name First Last Exhibit Space InformationExhibit space will be assigned based on level of sponsorship, exhibit location purchased, followed by first come basis.Product/Service to be DisplayedPlease indicate companies, if any, you desire NOT to be located adjacent to (i.e. competitor)Exhibitor RegistrationExhibit TypeExhibitor Booth - $3000Gold Support (Saturday Dinner) - $7000Silver Support (Sunday Breakfast) - $5000Bronze Support (Friday Afternoon Coffee Break) - $4000Bronze Support (Saturday Morning Coffee Break) - $4000Bronze Support (Sunday Morning Coffee Break) - $4000Optional - Extra Booth RepsNumber of extra booth repsOne extra booth rep - $250Two extra booth reps - $500The Welcome Reception and Family Dinner are complementary to exhibitors. Adult guests are welcome at $60/per person. Guests 12 years and younger are free.Optional - Adult Guests - $60/PersonNumber of guestsOne guest - $60.00Two guests - $120.00Three guests - $180.00Four guests - $240.00Optional - Saturday Family Activity Raptors are fascinating birds: the silent night-hunting owls, the day-hunting hawks, the fish eating ospreys, the fast flying falcons, and the mighty eagles. Birds of Prey Northwest will provide an educational program, bringing in a raptor biologist with 5 glove handled raptor species-including an eagle!Adult Tickets - Saturday Family ActivityAdult tickets $20.00 eachSelect # of adult ticketsOne guest - $20.00Two guests - $40.00Three guests - $60.00Four guests - $80.00Child Tickets - Saturday Family ActivityChildren ages 5-12 are $10 each; children under 5 years old are free.Select # of child ticketsOne child ticket - $10.00Two child tickets - $20.00Three child tickets - $30.00Four child tickets - $40.00TOTAL $0.00 CREDIT CARD American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Security Code Cardholder Name