GROUP ELECTRICAL REQUEST FORM



VENDOR SERVICES REQUEST FORM

GROUP: NC Chapter – American College of Surgeons ESM: Christine McCullough

VENDOR SET-UP DATE: Friday, July 19, 2019 @ 1:00 p.m. – 5:00 p.m.

VENDOR TEAR-DOWN DATE: Sunday, July 21, 2019 - after 10:45 a.m.

Location: Cardinal Ballroom

VENDOR NAME: BOOTH #:

|TYPE: |# NEEDED |CHARGES |

|TELEPHONE: | | |

|House Phone | |$75.00 |

|Outside Access Telephone | |$200.00 |

|DID Telephone | |$100.00 |

|HIGH SPEED INTERNET | |$250.00 |

|Hub or Wireless Router | |$50.00 additional to internet charge |

|LINES: | | |

|Fax | |$100.00 |

|PC | |$100.00 |

|ELECTRIC: | | |

|Standard 110 Volt Outlet | |$75.00 – one time charge |

| Standard 208 Volt Outlet | | |

|**20 Amp/1 Phase | |$75.00 |

|**20 Amp/3 Phase | |$75.00 |

|**30 Amp/1 Phase | |$75.00 |

|**30 Amp/3 Phase | |$75.00 |

|**50 Amp/1 Phase | |$75.00 |

|**50 Amp/3 Phase | |$75.00 |

|CORDS/CONNECTORS: | | |

|**25ft – 1 outlet extension cord | |$25.00 |

|**Multiple outlet strip | |$20.00 |

|Exhibition Company Hired: Yes No       |

*Full payment must accompany this form or your order will not be processed. Services are not refundable for no-shows or unused items. Refunds will only be granted outside 14 days.

METHOD OF PAYMENT (CHECK WILL NOT BE ACCEPTED)

CREDIT CARD:

Card # Exp. Security Code

Cardholder Name:

Receipt to be sent to:

(Fax number or email address)

VENDOR COMPANY NAME:

Address:

Phone:

Authorized Signer: Date:

PINEHURST, LLC

Conference Services

ATTN: Ms. Jo Prentiss

Joann.prentiss@

80 Carolina Vista Phone: 910-235-8201

Village of Pinehurst, NC 28374 Fax: 910-255-3368

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