"PARTICIPATION FORM for ExhibitorsDonations 32 Annual CSA"
PARTICIPATION FORM for Exhibitors/Donations 32nd Annual CSA Conference Dietitian Day—October 29; Conference—October 30-November 1 Bayfront Convention Center—Erie, Pennsylvania Exhibit Hall Dates October 29-31, 2009 Name of Company:____________________________________________________________________________________________ Authorized Company Representative:____________________________________________________________________________ E-mail Address:______________________________________________________________________________________________ Mailing Address:_____________________________________________________________________________________________ City, State, Zip Code:_________________________________________________________________________________________ Office Phone:_______________________________________ Cell Phone:_____________________________________________ Fax:__________________________________________ Website Address:_____________________________________________ Additional Company contacts and email addresses:______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ I prefer to receive further information by ______email _____US mail ____both email and US mail Annual CSA Conference Exhibit Hall Open Thursday 2:30 p.m. – Saturday 3:30 p.m. ___ I wish to participate as an exhibitor. ____ I am unable to attend, but wish to support the conference. (Please complete #1,and/or #2 and #3 below) (Please complete only #2 and/or #3 below.) 1. I wish to participate as an EXHIBITOR in the Annual CSA Conference Exhibit Hall. For the $450 registration fee I receive one 8’ by 8’ exhibit space with a 6’ skirted table, two chairs and a trashcan. Exhibit Space does not include pipe and drape. Exhibit fee includes one lunch ticket for Friday and Saturday lunch with the Conferees. NOTE: Fees increase to $600 after August 15, 2009 Total exhibit fee $_____________ For onsite hosting of your exhibit space by local CSA members, add $100 tax deductible donation (CSA will contact you) Local Host Donation $___________ The following individual(s) will be assisting in this exhibit space: (Provide name(s) and title(s): ____________________________________ _______________________________________________________________________________________________________________ ______ I request additional exhibit space(s) if available. (CSA will contact you) ______ I will need electricity and a power strip in my exhibit space (no additional charge). I will be bringing/shipping the following equipment requiring electricity:____________________________________________________________________________ _____________________________________________________________________________________________ ______ I will be cooking or baking in my exhibit space ______ NEW THIS YEAR! I wish to participate in a cooking demonstration on Thursday. (See Q and A) CSA will contact you. ______ Our products require on-site refrigeration. (CSA will contact you) ______ I will be selling non-food items and will obtain the necessary Pennsylvania forms (See Exhibitor Q and A for instructions) ______ I will be shipping product to CSA Conference and will need to receive shipping information. ______ I need wireless Internet access in my exhibit space (no additional charge). ______ I need the following meal tickets: #______ Friday Breakfast @ $25.00 #_______ extra Friday lunch @ $25.00 #______Saturday Breakfast @ $25.00 #_______extra Saturday lunch @ $25.00 #______ Sunday Breakfast @ $25.00 #_______ Friday Dinner @ $35.00 #_______ Saturday Banquet @ $40.00 Total meals $________________ PARTICIPATION FORM for Exhibitors/Donations April, 2009 2. I will submit on or before August 15, 2009, a black & white QUARTER-PAGE AD for the 31st Annual CSA Conference Syllabus at a cost of $175. Total Advertising $____________ 3. I would like to contribute to the success of the conference by providing: GLUTEN-FREE PRODUCT DONATIONS :(Please indicate products you wish to contribute and the ‘in-kind donation” value)) Donations towards Conference Menus, Oktoberfest Buffet, Children and Youth Programming, Dietitian Day Meals and Snacks Product(s):__________________________________________# servings __________________”in kind” value________________ __________________________________________# servings __________________”in kind” value_________________ __________________________________________# servings __________________”in kind” value_________________ __________________________________________# servings __________________”in kind” value________________ Total value donations $_____________ FINANCIAL SPONSORSHIP THROUGH EDUCATIONAL GRANTS (Please see attached Sponsorship Form for detailed descriptions) Pre-Conference Activities Conference Activities _______ Oktoberfest Buffet/Food Fair $5,000 _______ Conference Syllabus $5,000 _______ Registration Bags $2,500 Children and Youth Activities _______ Audio-visual support $5,000 _______ Conference Recordings $20,000 _______ KidZone/Teen Scene support $2,000 _______ Adult Registration Scholarships $400 each _______ KidZone/Teen Scene Scholarships $125 each _______ Young Adult Program support $1,000 _______ Young Adult Registration Scholarships $250 each _______ General Conference Support Dietitian Day Activities _______ General Support of CSA _______ Conference Speakers $1,500 each _______ Contact me about other sponsorship opportunities _______ Dietitian Day Conference Recordings $2,000 _______ CME/CEU Applications $1,500 _______ Dietitian Day Registration Scholarships $165 each _______ Dietitian Day Syllabus $1,000 _______ Dietitian Day Luncheon $2,500 _______ Dietitian Day Speakers $1,500 each Total Sponsorship $_______________ Total Payment $________ Participation form with full payment (check or credit card) must be received on or before August 15, 2009. Payment Method: Check ______ Payable to Celiac Sprue Association Credit Card ______ Select: Visa _____ MasterCard _____ Discover _____ American Express _____ Credit Card Number: _________________________________________________________ Security Code: __________ Expiration Date: ________________________ Signature: ________________________________________________________ Mail to: CSA P.O. Box 31700 Omaha, NE 68131 Fax # 402-643-4108 Exhibitors: Please include the following with your completed participation form: • Signed copy of the Conference Exhibitor Agreement signature page • Proof of liability insurance naming CSA and Bayfront Convention Center, Erie Pennsylvania • Listing of products with ingredient lists • Sample order form (if selling product) • Sample handouts Product Donations: Please include the following with your completed participation form: • Ingredient lists for donated products PARTICIPATION FORM for Exhibitors/Donations April, 2009