Sponsorship / Exhibitor Agreement & Selection Form - Part II

Method of Payment American Express MasterCard Visa Check #_________ Credit Card #: ____________________________ Exp . Date ( MM / YY ): _________ CVC #: ____________ Credit Card Billing Address : _____________________________________________________________ City : __________________________________ State : ___________________ Zip : _________________ Name on Card ( Please Print ): ____________________________________________________________ Signature ( Required ): ____________________________________________ Date : _________________ Attendee Registration Information First Name : _________________________________ Last Name : _______________________________ Badge Name ( if different from above ): _____________________________________________________ Title / Position : ________________________________ E-mail : __________________________________ Phone : ________________________________________ Fax : _________________________________ Mailing Address : ______________________________________________________________________ City : __________________________________ State : ______________________ Zip : ______________ Additional Attendee Registration First Name : _________________________________ Last Name : _______________________________ Badge Name ( if different from above ): _____________________________________________________ Title / Position : ________________________________ E-mail : __________________________________ Phone : ________________________________________ Fax : _________________________________ Mailing Address : ______________________________________________________________________ City : __________________________________ State : ______________________ Zip : ______________

Please send completed Sponsorship Agreement & Selection Forms Part I & II along with payment Confirmations will be sent once approved . Sponsorships and exhibit booths are assigned on a first-come , first-served basis and are non-refundable .

Tel : 972.934.4264 Email : cipc @ marketscout . com www . privateclientcouncil . com