EmailMe Form - 2011 AT Expo Vendor Registration

2011 AT Expo Vendor Registration

Oklahoma Assistive Technology Center
University of Oklahoma Health Sciences Center
Department of Rehabilitation Sciences
College of Allied Health
1600 N. Phillips
Oklahoma City, OK 73104
PH: 405-271-3625
TDD:405-271-1705
FAX: 405-271-1707
TOLL FREE: 800-700-6282

Assistive Technology Program for Oklahoma Public Schools

Assistive Technology Exposition Vendor Registration

Request Submitted by: *
First Last
Date *
MM / DD / YYYY
Company Information
Company Name
Primary Contact Representative Name
First Last
Additional Representative Name
First Last
Additional Representative Name
First Last
Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone
### - ### - ####
Additional Phone (Cell)
### - ### - ####
Extension
Fax Number
### - ### - ####
Primary Contact Email
Amount Due
Registration form recieved on or before October 21st, 2011: $100 fee
Registration form recieved after October 21st, 2011: $150 fee
Fee waived for:
State Agency
Non-Profit organization
Method of Payment
Check or PO via US mail
Credit card via website (www.theoatc.org)
Purchase Order or Check Number
Products to be Displayed
Please be specific and give formal names of products. This information will be used to describe your product line in the participants brochure:
Demonstration Booth:
Indicate the number of tables you need for your booth (each table is 3 feet deep x 6 feet long)
0
1
2
3
Floor Space & Electricity:
If you plan to bring large equipment indicate the amount of floor space you will need.
Length X Width
Will you require electricity to run your booth?
YES
NO
Will you need internet access to run your booth?
YES
NO
We are happy to offer a box lunch for our vendors this year (up to 2 per vendor). Would you like a box lunch? If so, how many do you need?
1
2
No thanks
BREAK OUT SESSIONS
We will schedule breakout sessions in seperate rooms during the conference so that you may present your products or services in a more formal setting and have the opportunity to answer specific questions from participants. You willl have one hour for this presentation.
Are you interested in doing a scheduled presentation?
YES
NO
We will provide a written description of each presentation to the participants. Please complete the information below. PLEASE BE SPECIFIC:WE WILL PRINT THIS INFORMATION IN THE PROGRAM EXACTLY AS IT IS WRITTEN BELOW.
Title of Presentation
Presenter(s)
Description of presentation (give an overview of the session and/or its importance and relevance.
Information about the presenter(s). Describe pertinent information about the presenter(s) such as education, experience in the field, background, etc.
Each break out room will have a computer projection system.
Please check additional equipment you will need during your presentation:
Overhead Projector
TV/DVD
Microphone
Other, please contact OATC
IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT AVIVA KRAUSE AT 800-700-6282 aviva-krause@ouhsc.edu, or CAMBER MOULTON AT 405-271-3625 camber-moulton@ouhsc.edu
Completed form and registration payment must be received by October 21, 2011. There will be an additional $50 fee for registration forms received after October 21st. To pay with a credit card online, click the "Vendor Online Payment" button located on the page that appears once you click the "Send Email" button below.

Powered by

EMF Web Form
Report Abuse