For Exhibitors

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Register your booth for the March 23 & 24, 2017 Conference

2017 Exhibitor Registration Form for download & mailing

Contact Information
*REQUIRED
*REQUIRED

BIA-NE Fundraiser at the Great Platte River Archway on Thursday, March 23.

6:30 to 8 p.m. $35 per person. Heavy hors d’oeuvres and cash bar.


$

* Some exhibitors give additional funds to help the Brain Injury Alliance to support its programs. If you wish to do so, put the additional amount in the box below. If you would like to be listed as an official sponsor of the BIA-NE, please the Sponsorship page. We are so appreciative of your gift. You will receive a letter to keep with your tax records for this contribution.

Please write a 50-word description of your business to be used in promotion. If you want to use the previous year's description, please put that.

*REQUIRED
Do you require electricity?

Booth Conditions, Rules and Regulations: The Alliance reserves the right to refuse the application of any party. The exhibitor agrees to make payment for space as outlined in this agreement. The BIA-NE shall determine the allocation of area and position of space. In no event shall the Alliance be responsible for any loss of or damage to exhibitor property.

*REQUIRED
*REQUIRED
*REQUIRED
Visa MasterCard American Express Discover Diners Club
*REQUIRED
/
*REQUIRED
? Visa®, Mastercard®, and Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.
*REQUIRED
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