PGC Exhibitor Registration Company Name*Primary Contact* First Last Title*Email* Work Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Names for Exhibitor Badges*Do you require electricity for your display?*YesNoProduct / Service to Be Displayed:*Large Machinery or Other Products?*YesNoPlease let us know if you will have large machinery or other products that may not be displayed on your 4 or 6 foot table.Large Machinery or Other Products Explanation:Competitors / Display LocationExhibitor Table Registration*4 Foot Table - $1,2006 Foot Table - $1,500No Table (choose this option if purchasing additional exhibitors below)Additional Exhibitors - $100 each Price: $100.00 Quantity: Total $0.00 REQUIRED FORM: By completing and submitting this Commercial Support Agreement, the company representative has read and agrees to abide by all Oregon Academy of Ophthalmology exhibit practices and regulations Please download, sign, scan and email or fax this agreement to (503) 210-1533. CANCELLATIONS will be charged a $100 service fee. No refunds after February 13, 2020.Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.