ICAC 2010 Conference Marketing Reservation FORM

International Child & Adolescent Conference XV

"Bridging Practices to Improve Academic and Social Competence

of Children & Youth"

Marketing & Exhibit Reservation Form

Organization Name

Primary Contact's First Name

Primary Contact's Last Name

Organization Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

(format xxx-xxx-xxxx)

Mobile Phone

(format xxx-xxx-xxxx)

FAX
(format xxx-xxx-xxxx)

E-mail

Confirm E-mail

Please indicate who will represent your organization at the conference:

Primary Contact will Attend Yes No (if no, please complete below)

Representative #1 First Name

Representative #1 Last Name

Representative #1 Email

Representative #2 First Name

Representative #2 Last Name

Representative #2 Email

Brief description of your organization/products/services for program (60-word max.):

Would you like to donate an item for the silent auction? No Yes

If yes, please provide a description and approximate value:

Marketing Options

Hold down the CTRL key to select multiple options.

Payment Options

USA Funds only please. Payable to Behavioral Institute for Children and Adolescents

(FED ID #41-1703237)

Total Fee:

Check check number:
mail with copy of reservation form

Purchase Order P.O. number:
mail/fax with copy of reservation form

Credit/Debit After you submit your registration using the SUBMIT button below, you will receive a confirmation page. Within a few days, you will receive an electronic PayPal invoice providing an opportunity to enter your credit/debit card information and activate your reservation. If you prefer, you may call us at 651-484-5510 to pay via phone.

REFUND POLICY: All refunds will be subject to a 20% handling charge. If you are unable to attend, submit notice in writing. NO refund requests received after October 4, 2010 will be honored.

SPECIAL NEEDS: Please indicate if you have any special needs or requests. Please indicate if you need an electrical outlet for your exhibit or if you wish to be placed adjacent to another exhibitor.

THANK YOU!