EmailMe Form - 2017 NCHN Conference Exhibitor Application

2017 NCHN Conference Exhibitor Opportunitiy

Please join us this year in our mission to support and strengthen health networks. Your presence exhibiting enables NCHN to serve its nationwide membership, supporting their efforts to improve healthcare access and services across the country. For more details please contact Larry Bedell at lbedell@nchn.org

Exhibitor Type Selection

Select your exhibitor type below. Table location priority is given to past exhibitors then on a first-paid basis.

Exhibitor Type *

Non-Profit

For Profit

Goverment

Select Only One!

Organization *

Exact name of organization for listing and signage

Description of your Organization/Service (as you would like to have it listed on the our websites and in the mobile event app): *

NCHN reserves the option to edit your description if it exceeds available space on the website or program (Recommended: 250 words or less).

Company Logo

High resolution (300dpi) logos, must be received by April 10, 2017.

Please enter the information below as you would like for it to appear on the conference website and in the mobile event app.

Optional: Upload your organization's logo

NOTE: If you do not upload a logo, please email a high resolution (300dpi) png or jpg copy to lweiss@nchn.org as soon as possible to have it displayed in the appropriate locations.

Contact Information

Please include the contact information for the exhibiting organization below.

Contact Person *

Contact Email *

This will be the email address NCHN uses to correspond with you.

Phone Number *

### - ### - ####

Website

Address

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

Booth Representative(s)

Please include name, and email address of any representative(s) attending the conference. The exhibit fee includes one complimentary conference registration. (Additional representatives may attend for an additional fee. Information is under the Payment section.)

Exhibitor Representatives

	Name	Title	Email
Complimentary Rep. 1
Additional Rep. 1 ($250)
Additional Rep. 2 ($250)

Exhibit Rate and Payment

Exhibit Rate is $899, which includes 1 representative. Additional representatives my attend for an additional $250 each to cover the cost of meals and breaks.

You may pay by check or for additional processing fees you may pay via PayPal.

Check Rate: Exhibit fee = $899, Additional Representatives = $250
PayPal Rate: Exhibit fee = $926, Additional Representatives = $258

If paying by check, please make the check payable to NCHN and mail to:
NCHN (National Cooperative of Health Networks Association)
c/o Rebecca J. Davis
400 South Main St.
Hardinsburg, KY 40143

If paying by PayPal, please use the PayPal link on the page you will be redirected to after successful submission of this application.

Number of additional (> 1) representative(s) *

0

1

2

Total Amount Due by Check

Check Number

Terms & Cancellation

ACCEPTANCE OF APPLICATION AND ASSIGNMENT OF SPACE
Applications for exhibit space are subject to review by NCHN's Conference Planning Committee. Space assignments will be based on number of years of prior NCHN sponsorship and then on a first-paid basis. No assignments will be made until payment is received. The 2017 Conference Planning Committee reserves the right to make such changes to the floor plan of displays as may be deemed necessary. Applications should be received by April 1, 2017. Those received after this deadline or after space is filled, will be placed on a waiting list and will be notified if space becomes available.

PAYMENT AND CANCELLATIONS
Exhibitor Applications must be accompanied with the exhibitor fee in order to confirm display space. No application will be processed without this fee. No refunds will be made for space not utilized during the conference. The 2017 Conference Planning Committee retains the option of returning funds.

COMMUNICATION
By providing your contact information, you authorize the National Cooperative of Health Networks to communicate with you regarding event information and to process your application.

If you have any questions about this form or planning your exhibit, please contact Linda K. Weiss at 217-549-4121 or lweiss@nchn.org

If you have questions about future exhibit and sponsorship opportunities, please contact Larry Bedell at lbedell@nchn.org

Terms & Cancellation *

I have read and understand the terms and the cancellation policy above.

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