EXHIBITOR REGISTRATION - PLEASE NOTE WE ACCEPT MC AND VISA ONLY

First Name *

Last Name *

Company

Address *

City *

State

Zip *

Phone *

Fax

Email *

Description of Product/Service

Please respond by January 1st, 2012 to recieve a discounted fee or by Monday, March 12, 2012 to recieve a regular fee.

Number of Tables

For Profit ($600.00/ $500.00 if registered by January 1st, 2012)
Non Profit ($475.00/ $375.00 if registered by January 1st, 2012)
Can't attend, but still want to reach MDA members? For $275.00 send us your promotional material to include in the attendee totes.

Electricity Needed? (Standard 110v, 60amp, single phase) YES! I will need a standard electrical outlet the day I exhibit.

Representatives from your company attending (Please indicate name(s) as you would like it to appear on a name badge)

Representative 1

Representative 2

* = Required Field