Please Print
Company Name_____________________________________________________________
Contact Name_______________________________________________________________
How should your name appear in the promotional materials?_________________________
___________________________________________________________________________
Mailing Address______________________________________________________________
City, State__________________________________________ Zip Code________________
Day Phone Number_________________Alternative Phone Number____________________
E-Mail Address______________________________________________________________
Fax______________Web Site (if applicable)_______________________________________
Product(s) being displayed_____________________________________________________
________________________________________________________________________________________
If you will be handing out free samples of food, please describe________________________
________________________________________________________________________________________
Will you need an electrical outlet? _______ If 'yes', how many outlets?_________________
Will you need any other special considerations? Describe___________________________
_______________________________________________________________________________________
Cost of vendor table on Tuesday, March 20 -- $150 for each 6-foot table
Cost of vendor table on Wednesday, March 21 -- $300 for each 6-foot table
Number of tables you are reserving on Tuesday, March 20 ___________
Number of tables you are reserving on Wednesday, March 21___________
Total amount enclosed for tables $____________
When will you be setting up your table? (check one)
_____early Tuesday morning, March 20th _____early Wednesday morning, March 21st
Authorized Signature___________________________________Date______________________
Make checks payable to:
Celiac Disease Conference
Mail Vendor Form to:
Chapter 111 Celiac Sprue Association
PO Box 5280
Fairlawn, OH 44334
Faxed forms will not be accepted.
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For Convention Committee Use Only
Date Vendor Form was received_____________ Number of tables to be reserved_________
Amount remitted: $____________ Table(s) number(s) assigned______________________
Notes______________________________________________________________________
_______________________________________________________________________________________
