National Association for State Community Services Programs ...
[pic] 2021 Winter Training Conference
Exhibitor/Sponsor Registration Form
Please complete and return with payment by February 26, 2021
|Please select your participation level and any ad-on packages below: |
|( |
|Platinum Sponsor ($5,500) Gold Sponsor ($3,750) Silver Sponsor ($2,500) Bronze Sponsor ($1,800) Exhibitor ($1,250) |
|Sponsorship Add-ons: Virtual Platforms Sponsorship Package (Only One Available) ($1,000) Marketing Sponsor ($1,000) Scrolling Banner Advertisement ($750) |
|Presentation/Session Sponsor ($750) |
| |
|Company/Organization:* |
|Address:* |City/State/Zip:* |
|Telephone:* |Website:* |
| |
|Representative Name:* |Title:* |
|Telephone:* |Email:* |
|Emergency Contact Name:* |Emergency Contact Telephone Number:* |
|NOTE: Bronze and Exhibitor levels offer registration for one representative. Additional representatives at those levels must pay the conference registration fee of|
|$500 for each additional representative. |
|Representative Name: |Title: |
|Telephone: |Email: |
|Emergency Contact Name: |Telephone Number: |
| |
Payment MUST accompany form.*
Check: # payable to NASCSP
To make payment via check, email this
completed form with a copy of your check
to rthomas@, then mail to:
NASCSP, 111 K Street NE, Suite 300
Washington, DC 20002
ATTN: Raymond Thomas
NASCSP Federal ID # 57-0715943
Questions: (202) 370-3660 or
rthomas@
No registration is processed without payment. Credit card and official, signed purchase order payments can be submitted online or via mail. No refunds will be offered for cancellations received after 02/26/21. Cancellations submitted prior to 02/26/21 will be refunded minus a $99 cancellation fee, which covers processing administrative costs. Please submit your cancellation in writing by email to rthomas@. Retain proof of NASCSP’s confirmation of receipt of your cancellation request.
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National Association for State
Comunity Servces Programs
ο MC ο Visa ο American Express
Card #: _______________________________________________________
Exp.Date:___________CVV#_________
Name on Card: _________________________________________________
Signature: ____________________________________________________
Card Billing Address if different from registrant address:
_____________________________________________________
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