Form

Information Table Request Form
Northwest Urological Society
56th Annual Meeting
December 4-5, 2009 Bellevue Hyatt Regency
www.nwurologicalsociety.org
Number of 6 'x 18" Information tables @$1000 each. (Not an exhibit booth. Located outside the exhibit hall and does not include registration for company representative)
Name of Person requesting Information Table(s)*
Company/Organization
Address:
City:
State:
Zip code:
Phone:
Fax:
E-mail:*
Country:
Special Requests:
Payment Option:

Credit Card Check
Pay by Credit Card
Check off as many Information Tables as needed.
Information Table $1,000.00 USD
Information Table $1,000.00 USD
Information Table $1,000.00 USD
Information Table $1,000.00 USD
Information Table $1,000.00 USD

Total: $0.00 USD
Pay by Check
1) Submit this online form and mail your Check To: NWUS, 914 164th St. SE, Suite B-12 #145, Mill Creek, WA 98012
Check Amount
Check Number
mailed on
- Month - Day Year
at
/ Hour Minutes
Should be Empty:

Information Table Request Form