2018 CIPC 2018-CIPC Conference Information Packet | Page 13

2018 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. Check Payments: (payable to MarketScout) Mail to: MarketScout/Diahann Doyen 12700 Park Central Drive, Suite 300 Dallas, TX 75251 Tel: [phone] Email: [email protected] Credit Card Payments: Return with form to [email protected] or fax at 972-934-4299 www.privateclientcouncil.com