Western Region – Vendor Registration

"*" indicates required fields

1Registrant Information

2Payment Information

Name

This field is for validation purposes and should be left unchanged.

Contact Information

Company Name*

Company

Contact Person*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Please provide a method to contact you in the event of special conference announcements. A registration confirmation email will be sent. Duplicate email addresses are not accepted.

Phone

Company Information

List items your company sells

List the names of the two company representatives attending. Additional people will have to register as a regular participant.

Representative #1

First Last Credentials

AARC Number

If your representative is an AARC member and is requesting CRCE credit, please provide their AARC membership number.

Representative #2

First Last Credentials

AARC Number

If your representative is an AARC member and is requesting CRCE credit, please provide their AARC membership number.

Terms and Conditions*

+ Payment are made via debit / credit card or PayPal. We accept Visa, MasterCard, or American Express through our secure online payment processing. Only institutional checks will be accepted. No personal checks.
+ Payment by institutional check must be received by April 22 or your registration maybe void.
+ Photographs taken during the conference may be used in future NYSSRC publications and promotions.
+ Click for our conference cancellations / refunds / privacy policy.
+ Any questions please contact us at info@nyssrc.org.

I agree to the Terms and Conditions

Options

My booth requires electrical outlets

My company is interested in sponsoring a refreshment break

Additional representatives

You will be contacted about your special requests.

Additional representatives.*

One additional

Two additional

Representative #3*

First Last Credentials

AARC Number

Representative #4*

First Last Credentials

AARC Number

Options Subtotal

$0.00

Vendor Acceptance Fee*

Price:

Booth reservation cost includes one table and two vendor representatives. Additional representatives must register as conference participant.

Discount code

Total

Payment choice*

Credit Card

When you click submit, you will be directed to the PayPal website to complete your payment. Once your payment is complete, you will be redirected back to the NYSSRC website for a confirmation message.

Institutional Payment Information

Payment made by institutional check requires the below information. Complete the fields below for the institution that will be issuing the check for this workshop. Do not use your personal address.

Institution Name*

Department Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*