*Company Name: ______________________________________________________________

*Contact Person: ________________________________ TITLE: ________________________

Contact Person’s Home Address: __________________________________________________

City: __________________________________ State: ___________ Zip Code: ______________

EMAIL: _________________________________ Home Phone: ( _____ ) _____ - ___________

Are you (being the contact person) attending the exhibit? ____ Yes  ____ No

____ Premier Support ($1,500)
(includes premier exhibit location; space as needed; display banner; program acknowledgement; food and beverage passes for up to six individuals)

____ Priority Support ($1,000)
(includes priority exhibit location; double space if needed; program acknowledgement; food and beverage passes for up to four individuals)

____ Exhibitor Support ($500)
(includes standard tabletop space; program acknowledgement; food/beverage passes for two people)

PLEASE NOTE: All exhibitor applications and payment in full must be received just as soon as possible.

Do you need electricity? ____ YES  ____ NO

Products, equipment or services to be exhibited and/or donated:

Please list below all others who will be attending from your company. Please add $25.00 per person per day for food and beverage if the number exceeds that which is outlined for each support level.

Names: _____________________________________________________________________________

$ _____________  Level of Support

$ _____________  Additional (Food)

$ _____________  TOTAL ENCLOSED

PLEASE MAKE CHECK PAYABLE TO: SOUTHERN ARIZONA TRAUMA NETWORK (SATNET)

Send Check to:
Clint Brown, Program Director
Southern Arizona Trauma Network
P.O. Box 43818
Tucson, AZ 85733-3818
(520)795-2170 FAX (520)626-5016