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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