Fall Conference Exhibitor Application

Request for Tabletop Display Space

89th Annual Fall Conference - November 3-4, 2011, Marriott, Overland Park, Kansas 66210, 913-451-8000

Please reserve a tabletop display space for our company at this meeting.

Company (name as it should appear):

Representative:    Position/Title

Typed name is equivalent to signature: Date

            Address        City, State, Zip

            Phone          FAX    E-mail

Indicate booth locations in order of preference by booth number (see Tentative Floor Plan).

   1st Choice: 2nd Choice: 3rd Choice: 4th Choice:
   If possible, please do not place us near the following companies or types of companies:

Payment Information

Cost Per 8’ Tabletop Space:            $1,500

Total number of space requested #

Total cost of space requested        $

Payment Method:    Check   Make check payable to: KCSWCS    Credit Card

Visa MasterCard Discover
Name of Cardholder

Credit Card Number

Exp Date MO/YR Security Code

Exhibit Fee

TAX ID# 44-0309060

Exhibitors will be acknowledged onsite at the meeting and in printed materials, deadline permitting.

Print & return, with payment to:

Sonora Thigpen

Kansas City Southwest Clinical Society

9229 Ward Parkway; Suite 280, Kansas City, MO 64114

Phone: 816/523-3383 / FAX:    816-523-3393 / email: info@kcswcs.org