2022 PGC Exhibitor Registration Today's Date MM slash DD slash YYYY 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 Proof of Vaccination Required Drop files here or Select files Accepted file types: jpg, pdf, png, Max. file size: 10 MB, Max. files: 10. Save time and upload proof of vaccination for each representative attending the 2022 PGC.Do you need electricity? Yes No Please list any companies you prefer not to be next to: Payment Information2022 Exhibitor Levels* Platinum - $2,000 Gold - $1,500 Silver - $1,200 VIRTUAL Gold - $750 VIRTUAL Silver - $500 For details on exhibitor levels, download the 2022 PGC Exhibitor Package.Additional Representatives - $100 eachNo Additional Representatives $0One Additional Representative $100Two Additional Representatives $200Three Additional Representatives $300Four Additional Representatives $400Five Additional Representatives $500Total $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 email or fax this signed agreement to (503) 210-1533.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged. Δ Cancellations will be charged a $100 service fee. No refunds after February 1, 2022.