Annual State Symposium Vendor / Sponsorship

Step 1 of 3 – Registrant Information

Contact Information

Company Name

Company

Contact Person*

First Last

International address*

Yes

Address*

Street Address Address Line 2 City State ZIP Code

International Address*

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

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.

Email*

Enter Email Confirm Email

Phone

International Phone

Company Information

Company description or product line to highlight

List the names of the two company representatives attending. Additional booth staff should register as conference participants if CRCE credit are sought. You will have the opportunity to register two additional representatives if no CRCE credit is required. 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.

First Representative

First Last Credentials

AARC Number

Second Representative

First Last Credentials

AARC 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 August 12 or your registration may be voided.
+ Click for our conference cancellations / refunds / privacy policy.
+ Photographs taken during the conference may be used in future NYSSRC publications and promotions.
+ Any questions please contact us at info@nyssrc.org.

I agree to the Terms and Conditions

Total

Payment choice*

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Online Payment Service

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*

International industry*

Yes

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

International Address*

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

International Phone*

Comments

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

Annual Symposium Vendor / Sponsorship

Contact Information

Company Information

Institutional Payment Information