Register Online 2014 Assistive Technology Conference Exhibitor Registration This form is for exhibitors ONLY. No presenters or attendees. Company / Agency / Organization InformationCompany Name* Company Website* Company Phone*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is the contact information (company name, address, phone, and website) the same contact information you want printed in the Program Book? Yes, use the contact information I already entered to be printed in the Program Book. No, the contact information for the program book needs to be different. Company Name for Program Book Company Phone for Program BookCompany Website for Program Book Company Address for Program Book Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Short Description of your Company/Agency for the Program BookLimited to 200 Characters.Who will be our contact at your company / agency?Who will be our contact at your company / agency?* Contact's Email Contact's PhoneExhibit StaffRequests for accommodations MUST be received by October 10, 2014.Exhibitor 1One lunch is included in your registration fees. Additional lunches must be purchased.Name* Prefix First Last Suffix Title* Lunch Choice*All exhibitors will be served a boxed lunch that includes a sandwich, chips, dessert, and a drink. Turkey sandwich Roast beef sandwich Tuna salad sandwich Ham and cheese and sandwich Chicken salad sandwich Accommodations NeededIf none leave blank. Accommodations must be received by October 10, 2014. Exhibitor 2Name Prefix First Last Suffix Title Will your second exhibitor be having lunch and breakfast?*YesNoLunch ChoiceAll exhibitors will be served a boxed lunch that includes a sandwich, chips, dessert, and a drink. Turkey sandwich Roast beef sandwich Tuna salad sandwich Ham and cheese and sandwich Chicken salad sandwich Accommodations NeededIf none leave blank. Accommodations must be received by October 10, 2014. Will you have additional exhibitors? No Yes Exhibitor 3Name* Prefix First Last Suffix Title Will your third exhibitor be having lunch and breakfast?*YesNoLunch ChoiceAll exhibitors will be served a boxed lunch that includes a sandwich, chips, dessert, and a drink. Turkey sandwich Roast beef sandwich Tuna salad sandwich Ham and cheese and sandwich Chicken salad sandwich Accommodations NeededIf none leave blank. Accommodations must be received by October 10, 2014. Title Accommodations NeededIf none leave blank. Accommodations must be received by October 10, 2014. These prices are early bird only and valid until June 2014.Commercial Exhibitor Quantity8 foot draped table with chairs and one lunch. Price: $400.00 Quantity Non-Profit Exhibitor Quantity8 foot draped table with chairs and one lunch. Price: $175.00 Quantity Additional Lunches (for each additional exhibitor) QuantityEnter the number of lunches you need after the 1 that is included in registration. Price: $35.00 Quantity Literature Table Display QuantityHave your catalogs or other literature displayed Price: $60.00 Quantity Advertising Options. For advertising in the program book, which is handed out to each attendees and kept throughout the year as a resource.Quarter Page Ad Quantity3.75" x 4.875" Price: $105.00 Quantity Half Page Ad Quantity7.5" x 4.875" Price: $175.00 Quantity Full Page Ad Quantity7.5" x 9.875" Price: $275.00 Quantity Website Ad Quantity200px x 200px ad will be displayed on the sidebar of www.AssistiveTechnologyConference.com until November 23, 2014 Price: $250.00 Quantity Sponsorship Options. Sponsors of the Assistive Technology Conference get maximum exposure, including being listed on promotional materials, newsletters, and in the program book.Conference SponsorGold SponsorSilver SponsorBronze SponsorNoneSession Sponsor QuantitySponsor a full session of educational programming Price: $500.00 Quantity Scholarship Sponsor QuantityScholarships are offered to people with disabilities who would otherwise be unable to attend the conference. By become a Scholarship Sponsor you name will be recognized in the Program Book with a 1/2 page ad. Price: $500.00 Quantity Breakfast / Break Sponsor QuantitySponsor the Breakfast or Coffee Break, your name will be displayed on the Breakfast or Break signage. Price: $350.00 Quantity Lanyard Sponsor QuantityYou company's logo will be printed on the lanyards that are given to each guest at the conference. Price: $650.00 Quantity Bag Sponsor QuantityYou company's logo will be printed on the reuseable bags that are given to each guest at the conference. Price: $650.00 Quantity CEU Sponsor Quantity Price: $1,500.00 Quantity TotalRegistration Fees total. $0.00 Payment Method* Credit Card via Paypal (you will be directed to Paypal) Check PO