Vendor Registration Form

73rd Annual National PAL Conference Crowne Plaza Dallas-Galleria Hotel, Addison,TX. May 1 – 5, 2017 Vendor Registration Form: Deadline: Monday, April 3, 2017 Please fill out the form below. You’ll need to print it out and mail it in to us along with your registration fee. Print/type the information below as it is to appear on your badge. If you have any questions, please call John More @ (561) 745-5535 or (732) 963-5353. You may email us at [email protected] Name of Organization: ___________________________________________________________ Representative: ______________________________________________ Address: ____________________________________________________ City: __________________________ State ____ Zip _________________ Business Phone: ______________________________________________ Business Fax: ________________________________________________ Email Address: _______________________________________________ Please list below any special needs, i.e. dietary, wheelchair accessibility, etc.

Payment Information: Please list the vendor type in the blanks below: _____ Non-Profit Partner $750.00 _____ Exhibitor $1,000.00 Total Enclosed $ _______

Please return this form prior to Monday, April 3, 2017 and make checks payable to: National PAL Conference 12161 Ken Adams Way Suite 110 RR Wellington, FL 33414