2012 Indiana ED Conference Marketing Reservation Form

30th Annual Indiana Annual Conference on Emotional Disabilities
From Pearls of Wisdom to Gems for the Future

Marketing 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:
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.):

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 with information about receiving an electronic invoice to pay via PayPal.

Your reservation fee entitles you to conference sessions, program, certificate, continental breakfasts, refreshment breaks, two lunches, one dinner and the Thursday evening social. 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 March 30, 2011 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!