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Conference  

Company Name: *
Contact Name: *
Title:
Address: *
Address 2:
City: *
State: *
Zip: *
Phone: *
Fax:
E-Mail Address: *
   
Exhibit Space Assignment  

Exhibit Space Assignment: There are a limited number of exhibitor spaces available. AHRA will assign one tabletop exhibit space per company on a first-come, first-served basis. You will be notified of your tabletop space after this information form is received and processed by AHRA.

Payment: Total cost is $1,500 per tabletop exhibit space. To reserve your space, return this form along with a 50% deposit of $750. Once AHRA receives the deposit, your tabletop space will be assigned, and a confirmation will be mailed. The balance of $750 is due on or before August 31, 2007. All payments must be made in US funds, drawn on US banks, payable to the American Healthcare Radiology Administrators.
 
     
Payment Information  

Total:
Name on Credit Card:  *
Credit Card:  *
Credit Card Number:   *
Authorization Code:
(See back of card)
Expiration Date: /   *
Is this a corporate credit card? Yes    No  *
Cancellation  

Cancellations received prior to August 11, 2007 will receive a full refund, less a $100.00 administrative fee. Cancellations received after August 11, 2007 will not receive a refund, and AHRA will retain all monies paid.
     
Rules & Regulations  

The complete set of rules will be mailed with the exhibitor service kit in July 2007. By submitting this application, you agree to abide by these rules.


You will receive an email confirmation after you hit the submit button.
If you do not receive a confirmation, please contact AHRA at (800) 334-AHRA.