CENTER FOR PROFESSIONAL DEVELOPMENT EXHIBIT APPLICATION FORM 5th

							                                     CENTER FOR PROFESSIONAL DEVELOPMENT

                                            EXHIBIT APPLICATION FORM
               5th Annual End of Life Conference          April 15th and 16th 2010
Company:
Address:
                       Number              Street                  City              State                Zip Code
Contact Person:                                                                  Title:
Phone #: (               )                  Fax #: (      )                            Cell #: (   )
E-mail address:
Home Page Address: (URL)
Representative (s) from your company who will be present:          1.
(As name badge should read)                                        2.
Product or services provided by your company:



Brief description of the exhibit:



Please note: The exhibit space will consist of one table (approximately 6 feet by 3 feet) and two chairs. Total space per exhibit
will be approximately 9 feet by 6 feet. If you need additional space, please let us know in advance so we can plan accordingly.
Specific Requirements of the Exhibit (Please check appropriate boxes)
                                          Phone: Number of phone lines needed  1  2  3  4
                                          Types of Phone Line Needed:  Standard  Direct dial out  ISDN
                                          Electricity: Number of outlets  1  2  3  4 or more
                                          Monitor / State Monitor Size
                                          No Table Needed:                   
                                          Other

Please note: For phone lines, electrical outlets, and/or long distance toll calls, you will be responsible for costs. Contact
information will be sent with confirmation of exhibit space.
Other requirements:

REGISTRATION FEE: FULL EXHIBIT: Before 2/15/10 $295.00                    COMBINED EXHIBIT: Before 2/15/10 $150.00
                               After 2/15/10 $395.00                                       After 2/15/10 $250.00
                  NON PROFIT: Registration fee waived

Checks are payable to (in US funds) RUTGERS THE STATE UNIVERSITY OF NEW JERSEY
Credit Card Payment Information:      Credit Card:  Visa  Master Card  Discover (Sorry No American Express)
Name on card:                                                           Card number:
Expiration Date:         /    /       Amount to be charged: $                 Signature:
Mail, email or fax registration with appropriate payment to:                 Mail: Dr Gayle A Pearson
Fax #: (973) 353-1700                                                        Rutgers College of Nursing
Web Site: http://nursing.rutgers.edu/cpd                                     Center For Professional Development
Email: cpdn@rutgers.edu                                                      175 University Ave Conklin Hall Room 244
Phone: (973) 353-5895                                                         Newark, New Jersey 07102



Note: Exhibit fees include registration for two persons only. Additional representatives of the company will be required to
register for the full conference, or second exhibit space may be requested.
                        CENTER FOR PROFESSIONAL DEVELOPMENT
                                 SPONSORSHIP FORM


Title of Conference:            5th Annual End of Life Conference__________________________________

Company Name:

Contact Person:

Address:

City/State/Zip:

Daytime:                                         Cell Phone:

Fax:

Email:
We will participate in the following sponsorship opportunity (ies):

          Welcoming Reception………………………..………………… $ 3,500
          Luncheon Subsidy......................................................$ 2,500
          Continental Breakfast…………………………….……………..$ 2,000
          Keynote Speaker Subsidy …………….……………………...…$ 1,000
          Refreshment Breaks..………………………...………………...$ 1,500

                                       AMOUNT OF SPONSORSHIP                     $
NOTE: SPONSORSHIP MAY BE FOR A PARTIAL AMOUNT.
Please return this form and a camera-ready logo along with your check payable to
Rutgers, The State University of New Jersey
                         Mail to:
                       Dr. Gayle A Pearson
                       Rutgers College of Nursing
                       Center For Professional Development
                       175 University Avenue Conklin Hall Room 244
                       Newark, New Jersey 07102
                       Phone: 973-353-5895  FAX: 973-353-1700
                       Website: http://nursing.rutgers.edu/cpd
                       Email: cpdn@rutgers.edu

 Check to Follow
 Enclosed Credit Card Payment Information:
  Credit Card:  Visa    MasterCard         Discover
   Name on card:
   Card number:
   Expiration Date:             /   /          Amount to be charged: $
   Signature: