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Authors Avenue Registration Form Gen Con Indy 2011

VIEWS: 4 PAGES: 2

									                                                                                                  Gen Con Indy 2011
                                                                                   Authors' Avenue Registration Form
August 4-7, 2011 | Indiana Convention Center | Indianapolis, IN

    Please check one:                       Author                             Publisher

CONTACT DETAILS

Legal Name:
Publisher/Company Name:
Exhibiting/Pen Name (if different):
Address:


City/Town:                                                                                               Is this a new address?
ST/Province:                                      Postal Code:                                                 Yes          No
Country:
Phone #:
Email:


ACCOUNT INFORMATION

Gen Con (RUBI) Account ID Number **:
** You must have an account in our registration system (RUBI) . Your registration form will not be processed without
an Account and the ID number listed.
Email (associated with RUBI acct, if different from above):

Additional Badge Names:




PROFILE INFORMATION

Website:

Type of work (select all that apply):                Fantasy          Sci/Fi                Horror                   Military
           Other:
Brief description of your work or titles:


Are you a returning as an exhibiter at Authors' Avenue?               Yes              No
If yes, how many years have you attended?
       1 yr               2 yrs         3 yrs                 4 yrs            5 yrs           6-9 yrs               10+ yrs




                                                                                                         (continued on next page)



    AARegForm-Indy11                                                                                                   Page 1 of 2
SALES PAYOUT INFORMATION

Does Gen Con have an IRS W9 or 8233 (International only) Form on file for you?                                               Yes             No
If no, have you included one with your Art Show Registration Form submission?                                                Yes             No
If you are unsure, please include one with your registration. If you do not have a W9 or 8233 on file with
Gen Con LLC's Finance department, your payout will be delayed.

Would you prefer to have your money wired to your bank account?                                                              Yes             No
  There is a $35 fee for wiring. This fee will be taken out of your final sales payout.
If yes, have you provided Gen Con with the Wire Transfer form with your registration submission?
                                                                                                                             Yes             No


EXHIBIT SPACE / PRICING & ADDITIONAL BADGE PURCHASE
                 Description                Price                                                 Quantity                           Total
2-panel Author Table                        $175
2-panel Publisher Table                                                  $243
                                                                                              Table Sub-Total

                Additional Badge Purchase (Pre-Reg only)                                          Quantity                           Total
Badge Cost (limit 4 people per table)                                      $68
Plus 6% Marion County Admissions Tax
                                                                 x 6% (per Badge)
(per badge)
Author table receives one "exhibitor" badge; Publisher table receives two.                   Badge Sub-Total
Additional badges may be purchased either during the pre-registration period
or onsite. Limit of four people to staff either table.                                              Balance Due:


METHOD OF PAYMENT

Please select one:                  Visa           Mastercard                 AmEx          Discover              Money Order                 Check

To pay by credit card, please include the following information:

Name on Card:                                                                                     Expiration Date:
Card Number:                                                                                   CCV # (3-4 digits on back of card):

Please make checks or money orders payable to Gen Con LLC. There is a $60 fee on all returned checks.
Payment must be enclosed in order for this form to be processed.


By signing below I affirm that I have read the Authors' Avenue 2011 Rules & Guidelines and agree to comply.

Print Name:

Signed:                                                                                                      Date:



All fields must be filled out in order to process your Gen Con Indy Authors' Avenue Registration Form.

Send completed form(s) with payment to:                        Gen Con LLC / Authors' Ave - Indy 2011
                                                               Attn: Jeannette LeGault
                                                               120 Lakeside Avenue, #100
                                                               Seattle, WA 98122 USA

                                                               Email: jeannette.legault@gencon.com
                                                               Fax: 206.957.1862


    AARegForm-Indy11                                                                                                                   Page 2 of 2

								
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