Florida School of Addictions Studies, Inc.
EXHIBITOR REGISTRATION & AGREEMENT FORM
(Please Print)

Name of Agency or Individual:____________________________________________________________

Mailing Address:_________________________________________________________________________
(P. O. or Street Address City State Zip)

Contact Person:______________________________________________

Day Phone #: (______)______________

Fax # (______)______________

E-Mail Address: ___________________________________

Website Address:__________________________________

Brief Description of Product(s) or Service to be Displayed:________________________________________

TOTAL NUMBER OF EXHIBIT SPACES REQUESTED AT $400 EACH: ______
(All exhibit space is arranged against the walls of the main hallway of the University Center.
Each exhibit space is approximately 8’x10’ and
includes a draped display table, 2 chairs and electrical hook-up if needed.
Your exhibitor fee covers your exhibit space and inclusion of 2 representatives for all meals and
special events that take place at the school.)

# of extra chairs: ____

Electrical hook-up requested?: ______ Yes____ No____

# of titles @$25/each for “Take One” Table: _____

# of titles @$35/each Stuffing Service ______

Other specific needs:___________________________________________________________________________

Names of Designated On-Site Staff

1.___________________________________________

2.___________________________________________

Names of Additional On-Site Personnel*

1.___________________________________________

2.___________________________________________

*Two (2) exhibitor staff are included with the exhibit space rental fee. Fee includes attendance at all
meals, breaks, and receptions that are open to registered students.
Fee does not include attendance of educational tracks.
Additional staff may attend for fee of $200 each, which includes all meals, breaks, and receptions that are open to registered students.

I(we) hereby submit our registration information as an exhibitor at the 2007 Florida School of Addictions Studies
and agree to abide by the terms and conditions described in the Exhibitor Information included with our exhibitor letter of invitation.

Signed:_________________________________________________ Date Signed:________________

Name Printed:__________________________________________

Title:_______________________________

Please make checks payable to Florida School of Addictions Studies and mail this form with payment to:
FSAS Registrar
Florida School of Addictions Studies
1725 Art Museum Drive
Jacksonville, FL 32207

To pay with credit card, please include the following information and fax completed form to FSAS Registrar at (904) 399-8001.

Card Type: ___________________ Card Number:_______________________________________

Date Card Expires:___________

Card Holder:___________________________________________

Authorized Signature:___________________________