EXHIBITOR REQUEST FORM

Northwest Urological Society 56th ANNUAL

December 4-5, 2009
The Hyatt Regency
900 Bellevue Way NE
Bellevue, WA 98004
(425) 462-1234

Electrical Outlet Needed: Yes___ No____

_____ # of 8 x 10 Exhibit Booths @ $2000 each

(includes registration for up to 3 company representatives)

NAME of Point Person for the Exhibit(s):__________________________________ _______________

COMPANY:_______________________________________________________________________

ADDRESS:________________________________________________________________________

CITY:___________________________________________ STATE:_____ ZIP: ________________

TELEPHONE:___________________________________ FAX:_____________________________

EMAIL: __________________________________________________________________________

Names of Representatives staffing exhibit booth: (email information is REQUIRED)

_______________________________________ email ___________________________

_______________________________________ email ___________________________

_______________________________________ email ___________________________

• NOTE: ADDITIONAL REPRESENTATIVES WILL NEED TO PAY AN $85 REGISTRATION FEE TO

HELP COVER THE EXPENSE OF MEALS PROVIDED.

$________________ Check made payable to the NWUS (U.S. Funds Only)

(Space will only be reserved upon receipt of payment)

SPECIAL REQUESTS:_____________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

NOTE: Credit card payments are welcome.

RETURN THIS FORM TO: Northwest Urological Society Tax ID# 91-6071545
914 164th St. SE, Suite B-12 #145
(866) 800-3118 office Mill Creek, WA 98012
(360) 668-4053 fax www.nwurologicalsociety.org

CREDIT CARD #______________________________________________________EXP DATE___________