Senior Connection
PO Box 11929
Prescott AZ 86304
(928) 778-3747
Expo@SeniorConnection.us
Secure Expo Registration Form
New Enrollment
Already A Member
Agency Name
Agency Street Address
Agency City State Zip
Agency Phone
Agency Fax
Agency Website
Contact Name
Contact Phone Number
Contact Email Address
TABLES (All tables are 6' long):
Yes, I need to borrow one of your tables
No, I'm bringing my own table
Electricity (Limited number of booths):
Yes, I need a booth with Electricity access
No, I do not need Electricity access
Payment Options
Credit Card
Purchase Order
Paypal
Check
Name on Credit Card
Credit Card Number
Expiration Date
Street Address from Statement
City State Zip
Check Number
Purchase Order Number
If you want to pay through Paypal:
Please provide PayPal Account Email
(We will send you a Paypal Invoice shortly)
Annual Membership Fee: $375, includes Booth at
Fall Senior Connection Seniors & Caregivers Conference & Expo
and other GREAT Services!
Be sure to print a copy of this form for your records before submitting.
Thank You!
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