Company Name:

Description of Product/Service:

Address:

City: ST Zip:

Phone: Fax:

E-Mail:

Exhibitor Contact

Booth Representative 1:

Booth Representative 2:

BOOTH FEES

ADVERTISING OPPORTUNITIES

The AKOA is offering an opportunity for you to reach the optometrists throughout the state. Your company has the option to advertise in our Registration Booklet or in the Onsite Proceedings Manual.

Please submit high-quality ad files by e-mail to akoa@alaska.com before August 1, 2010

PAYMENT PROCESSING

Total Enclosed $

Credit Card Number ______________________________Expiration Date ________

Cardholder's Name _____________________________________

Address (as shown on credit card statement) ______________________________________

Zip Code _____________________

Signature ___________________________________________ Date: ____________

Indemnity and Limitation of Liability:
Given the agreement contained on this page, and subject to the conditions expressed herein, the company shown on the document agrees to hold the Alaska Optometric Association and the venue facility harmless for any and all liability for injuries and damages caused to their property or personnel or any member of the public incurred through the use of the exhibit space or displays allotted at the venue.

SUBMITTING FORM

1. Fill in the appropriate blanks.

2. Print Form

3. Complete Payment Processing Section

4. Mail or Fax to:

Alaska Optometric Association
1689 C Street, Ste 222
Anchorage, AK 99501
Fax: (907) 272 7532