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Registration
Exhibitor and Sponsor Registration

Contact Information

Salutation:
  
First Name:
  
Last Name:
  
Address:
  

City:
  
State:
  
Zip:
Country:
  
E-mail:
  
Phone:
  
Fax:
  
Diet Restrictions:
  
     
Exhibitor & Sponsor Information
Company Name:
(exactly as it should appear on signage) 		 
Are you bringing a portable pre-fab tradeshow booth?
(please check one) 		  Yes No
Special requests for set-up:
(i.e., electrical outlet, extension cords)		  
Please enter the exhibit and/or sponsor dollar amount that you are contributing:  
Please do not enter commas or decimals
This amount will automatically calculated into the "Total Fees Due" below.
 

Tuesday Night Cocktail Reception & Dinner Registration
Optional Sign-Up For Those Not Registered For The Meeting Or For Anyone Not Included In Your Sponsorship Or Exhibit Package
You may invite additional associates from your company or guest(s) to the Tuesday night Cocktail Reception & Dinner at an additional cost of $110 per person. Additional dinner registrations are non-refundable after February 3th, 2013.

Please check below for each additional dinners needed for non-registered guests.
Dinner @ $110
Dinner @ $110
Dinner @ $110
Dinner @ $110
Dinner @ $110
    *Total Conference Fees Due:
       
Please make check payable to Aspen Urological Conference and mail to the following address:

Aspen Urological Conference
c/o Barb Werderitch
900 Rand Road, Suite 120
Des Plaines, IL 60016
Phone: (847) 823-3185
Fax: (847) 823-3318

Unfortunately, conference fees cannot be paid by credit card. All conference fees should be received no later than January 24, 2013.

You may print out this page before you hit the "Submit" button. After hitting the "Submit" button, you will see a confirmation of the information you sent to us.  An e-mail confirmation from Barb Werderitch will be sent to you in January confirming your registration details.

If you have any changes or cancellations after submitting this form, DO NOT submit another form. For assistance, call Jeanette Sofia at (847) 823-3185 or e-mail bwerderitch@uropartners.com.

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