Hispanic Wellness Coalition: 2012 Sponsorship/Exhibitor Registration Form: Providing healthcare education and access to wellness services

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2012 Sponsorship/Exhibitor Registration Form
The information on this form will be used to prepare your company’s listing that will appear in the Hispanic Wellness Coalition provider directory for the 2012 Hispanic Wellness Fair. We must receive this registration form by May 1, 2012 to guarantee recognition in all our promotional materials. Click here to Open 2012 Sponsorship/Exhibitor Registration Form pdf to review sponsorship levels and benefits.
0	Sponsorship Level
1	Company Name (or N/A)	*Required
2	Contact Person	*Required
3	Email Address	*Required
4	Phone	*Required
5	Web Site Address (or N/A)	*Required
6	Fax (or N/A)	*Required
7	Cell
8	Mailing Address	*Required
9	Alternate Contact
10	Alternate Contact Phone
11	Services Exhibitor will Provide at Event	*Required
12	Will you require privacy booths? If so- how many?	*Required
13	Will you require bilingual (Spanish/English Interpreters? If so how many?	*Required
14	Will you require (Spanish/English)Volunteers? If so- how many?	*Required
17	How many staff- including yourself will be working your booth the entire day? (lunch will be provided only to those who will work the entire day)	*Required
18	We understand and confirm this agreement and agree to abide by the regulations.(Please enter your initials as a digital signature):	*Required
	Enter this validation code: BOHJCLE	*Required

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