2023 PGC Exhibitor Registration Today's Date MM slash DD slash YYYY Company Name* Primary Contact* First Last Title* Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Exhibitor Badge InformationName (first & last)EmailCell Phone Do you need electricity?* Yes No Please list any companies you prefer not to be next to: Payment Information2023 Exhibitor Levels* Platinum - $2,000 (includes up to 4 representatives) Gold - $1,500 (includes up to 2 representatives) Silver - $1,200 (includes one representative) EXHIBITOR MATERIALS: 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 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged. Cancellations will be charged a $100 service fee. No refunds after February 1, 2023.