Annual Conference – Sponsorship – Florida Association of Community Health Centers

Step 1 of 5

Conference Planning Contact

Who will receive the emails regarding planning, booth assignments and billing related information?

Planning Contact Name(Required)

First Last

Planning Contact Title

Planning Contact Email(Required)

Planning Contact Phone(Required)

Company App Listing

What information would you like printed in the Conference App?

Organization(Required)

Briefly describe your organization’s product and/or service:(Required)

App Listing Contact Name(Required)

First Last

Title(Required)

App Listing Email(Required)

App Listing Phone

Address to be listed in App

Street Address City State ZIP Code

Booth Attendees

Please provide this information for anyone attending on behalf of your organization. The accuracy of this information is important to ensure access to updates and the Event App.

1. Attendee Name

First Last

1. Attendee Title

1. Attendee Email

2. Attendee Name

First Last

2. Attendee Title

2. Attendee Email

3. Attendee Name

First Last

3. Attendee Title

3. Attendee Email

4. Attendee Name

First Last

4. Attendee Title

4. Attendee Email

5. Attendee Name

First Last

5. Attendee Title

5. Attendee Email

6. Attendee Name

First Last

6. Attendee Title

6. Attendee Email

7. Attendee Name

First Last

7. Attendee Title

7. Attendee Email

8. Attendee Name

First Last

8. Attendee Title

8. Attendee Email

Additional Attendee #1 Name

First Last

Additional Attendee #1 Title

Additional Attendee #1 Email

Additional Attendee #2 Name

First Last

Additional Attendee #2 Title

Additional Attendee #2 Email

Additional Attendee #3 Name

First Last

Additional Attendee #3 Title

Additional Attendee #3 Email

Additional Attendee #4 Name

First Last

Additional Attendee #4 Title

Additional Attendee #4 Email

Additional Attendee #5 Name

First Last

Additional Attendee #5 Title

Additional Attendee #5 Email

Additional Attendee #6 Name

First Last

Additional Attendee #6 Title

Additional Attendee #6 Email

Additional Attendee #7 Name

First Last

Additional Attendee #7 Title

Additional Attendee #7 Email

Additional Attendee #8 Name

First Last

Additional Attendee #8 Title

Additional Attendee #8 Email

Total

Coupon

If you have been provided a Coupon Code, please enter it in this space and hit 'Apply'.

Form of Payment(Required)

Pay with a Check

Pay with a Credit Card

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Refund Policy Acknowledgement(Required)

By submitting this registration form, I acknowledge and agree that all payments made to secure Sponsorships and/or Exhibitor Booths are final and non-refundable.

Sponsorship & Exhibitor Registration Form

Conference Planning Contact

Company App Listing

Sponsorship Level

Booth Attendees