MAER 2017 Fall Conference VENDOR Registration * 11/2 & 3/2017 * MS Schools for the Blind and Deaf, 1252 Eastover Dr., Jackson, MS

REGISTRATION FORM -

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* 1. My first and last name is...

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* 2. I am a member of Association for Education and Rehabilitation of the Blind and Visually Impaired (AER).

Yes

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* 3. I wish to exhibit at the Fall Conference. I will represent a...

For profit entity: Registration Fee is $125.00 for BOTH days which includes one 72" table, 2 lunch(es) and snack per day for up to 2 people, and inclusion of printed materials in the Conference Information Packet.

Non-profit entity: Registration Fee is $35.00 for BOTH days which includes one 72" table, 2 lunch(es), and snack per day for up to 2 people, and inclusion of printed materials in the Conference Information Packet.

Other (please specify)

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* 4. The company or organization I represent is...

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* 5. My job title/position with the company or organization I represent is...

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* 6. As a Vendor, I will need the following:

I only need the one (1) table included in the Vendor Registration Fee.

I'd rather have two (2) tables for my exhibit. Please provide an extra table for my booth area.

I need access to electricity.

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* 7. The following methods are the best way to contact me. My primary phone number is listed in the "Open Field" below.

Voice/Phone

Text Message

Either

Number:

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* 8. I have a second phone number I wish to share...

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* 9. My current mailing address is...

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* 10. My current email address is...

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* 11. I will bring a colleague whose name is...

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* 12. My colleague's phone contact is:

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* 13. My colleague's email address is:

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* 14. I have the following required dietary needs regarding any meals and snacks.

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* 15. My colleague requires the following required dietary needs regarding any provided meals and snacks.

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* 16. Please see the required communication access needs (ASL Interpreter, braille, large print, electronic documents, etc.) below that will serve me best during the conference.

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* 17. Please see the required communication access needs (ASL Interpreter, braille, large print, electronic documents, etc.) below that will serve MY Colleague best during the conference.

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* 18. The type of Interpreter I require for accessing the information at this Conference is ...

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* 19. The type of Interpreter MY Colleague requires for accessing the information at this Conference is ...

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* 20. I am interested in receiving the following kind(s) of Continuing Education Credits:

Other (may not be available):

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* 21. MY Colleague is interested in receiving the following kind(s) of Continuing Education Credits:

Other (may not be available):

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* 22. I will pay the Vendor Registration fee with a...

Personal or Company Check and I will mail it to the P.O. Box below.

Agency will use Paymode-X

Other method:

MAER Federal Tax Id: 62-1305617 _*Use Paymode-X OR make check payable to MAER and send to:

Fall Conference - VENDOR
MAER
P. O. Box 705
Madison, MS 39130

Thank you for submitting Part A of your registration. We look forward to receiving your payment which is Part B of the registration process. Please look for a confirmation email from us regarding your online registration (Part A) and also for a receipt of your payment (Part B). You will be recognized as fully registered only after Part B has been completed and confirmed (payment has been received).

If you have any questions, please call Herb Humphrey, 601-984-3264 or email hhumphrey@msblind.org or Toni Hollingsworth, 228-249-9668 or email at hollingsworth.toni@gmail.com