Date

This form confirms that

(Publication or Company)

Will be represented by (name)

Position

Office address:

Telephone

Fax

E-mail

How many people will staff the booth?

Form of Payment for the Booth and Registration Fees

(Please send payment to the IAPA offices)

Check -- (payable to the IAPA, in U.S. dollars)

Check number

(An additional 5% is charged to the credit card for handling costs. Please authorize the charge.)

American Express

Visa

Mastercard

Number

Security Code

Date of expiration

Bank Transfer – Please contact us for more information.

CANCELLATION OF BOOTH RESERVATION:

Full reimbursement if notification in writing received before September 1st; 50% if received September 2nd and October 7th. After October 8th, no reimbursement will be made.

Will be represented by (name)

E-mail

Booth number that we wish to have:

Name that will identify our booth: