NCQA Exhibitor and Sponsorship Registration Form for Mail and Fax
Name (include credentials):_________________________________________________________
Badge Name:____________________________________________________________________ Organization Category
Title:___________________________________________________________________________ (please check one box)
Organization:____________________________________________________________________ Software IT
Street Address:__________________________________________________________________ Medical Record Review
□ Exhibitor - $1750
□ Cyber Café Sponsorship - $3000 Note: Sponsorships include 6-foot exhibit table, free promotion within program guide, company
□ Happy Hour Sponsorship - $5000 name on website and additional recognition as stated on website.
□ Breakfast Sponsorship - $3000
□ Arlington, VA
□ Phoenix, AZ
Easy Ways to Register!
Call NCQA Customer Support at (888) 275-7585 with your credit card information
Fax this form with your credit card information to the Conference Registrar at (202) 955-3531
Mail this form with your check to: NCQA, Department 4038, Washington, D.C. 20042-4038
If you are sending a payment overnight, send to: NCQA, 2000 L Street, NW, Suite 500, Washington, D.C. 20036
Check payable to NCQA Enclosed (check number and amount):_________________________________________________________________
Visa MasterCard American Express
Cardholder’s Name:_____________________________________Cardholder’s Signature_______________________________________________
Card Number:______________________________________________________Expiration Date:________________________________________
Payment Once you have received your confirmation, please
Payment in full is required to process your contact the facility where the seminar will be held to
registration. NCQA will not accept third-party checks. reserve your room. NCQA does not validate or
reimburse for parking.
You will receive a confirmation via fax or e-mail of Dress
your registration and an exhibiting/sponsorship Casual business attire is appropriate. Please
packet from NCQA within five business days of remember, conference rooms tend to be cool. We
receipt of your payment. Because space is limited, recommend you bring a sweater or light jacket.
please wait to make travel and hotel arrangements
until you have received confirmation of your Refund Policy
registration. Exhibitors canceling more than 10 days before the
seminar are entitled to a refund of their registration
Special Needs fee, less a $150 processing charge. Cancellations
If you have special needs, please contact NCQA must be received in writing.
Customer Support at least seven business days prior
to the seminar. A representative can be reached at There are no refunds for exhibitor cancellations
(888) 275-7585, Monday-Friday, 8:30 am-5:30 pm received less than 10 days prior to the seminar.
Eastern Time, or e-mail us at There are no refunds for sponsorship cancellations.
firstname.lastname@example.org to ensure your