Please select event you wish to register for:
 Queens Brooklyn

Company (required)

Representative (required)

Rep Email (required)

Address

Phone

Fax

Company Website

Does your company want to provide a health screening?
Please describe.

Number of 6x3 tables requested

Table location preference (sponsor section or main floor exhibitor section):

The undersigned hereby authorizes BMD Marketing Company, LLC to reserve exhibit space for use by the company or organization listed above during the Health Expo. By initialing below, the undersigned represents that he/she has been authorized to execute this binding contract on behalf of the named Exhibitor.

Initials (required)

Name (required)

Title (required)

Date (required)

Comp or promotional code

Payment Info

 Check Credit Card (Form Below)

Credit card authorization:
I authorize BMD Marketing Company to charge the credit card listed below:

Name on Card

Credit Card Number

Expiration Date

Amount of Charge

Billing Address