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| 2012 - 2013 APPLICATION FOR EXHIBIT SPACE AMERICAN ASSOCIATION OF DENTAL BOARDS _____MID-YEAR MEETING, ADA Headquarters, Chicago, IL: APRIL 22 - 23, 2012 _____ANNUAL MEETING, San Francisco, CA: OCTOBER 17 - 18, 2012 |
| Exhibitor Information (please print or type): EXHIBITOR: (Company Name): ________________________________________________________ CONTACT NAME: _____________________________ POSITION: __________________________ BY (Signature of Individual): __________________________________________________________ ADDRESS OF COMPANY: ____________________________________________________________ CITY/STATE/ZIP: ___________________________________________________________________ PHONE (Business): ____________________ PHONE (Toll free): _____________________________ FAX: _________________________________ E-MAIL: _____________________________________ WEB PAGE (for registrant materials): ___________________________________________________ PRODUCT OR SERVICE DESCRIPTION: ________________________________________________ |
| Exhibit Fee: $2,000 We hereby make application for exhibit space at: AADB 2012 Mid-Year Meeting, April 22 _____ April 23_____ AADB 2012 Annual Meeting, October 17 _____ October 18 _____ |
Send this signed contract to: American Association of Dental Boards 211 E. Chicago Ave., Suite 760 Chicago, IL 60611 Telephone: 312-440-7464 FAX: 312-440-3525 email: info@dentalboards.org |
| METHOD OF PAYMENT: ___ Check or ___ International Money Order (in US$) is enclosed For Credit Card Payment: * VISA * Master Card * American Express Credit Card No. ____________________________________ Expiration Date ___________________________ Amount Charged $___________ Name as it appears on the card ___________________________________ Authorized signature_____________________________________________ When signed below, I/We agree to abide by the entire Exhibiting Rules and Regulations of the AADB which we have read and are aware that these Rules and Regulations and all applicable rules, regulations and stipulations of the meeting facility, are an integral part of this contract. Exhibitor Name_____________________ Signature _____________________Title______________Date_________ (Please print) AADB Authorization ___________________ Signature ____________________ Title_____________Date_________ (Please print) |