EXHIBITOR
Registration Form
Johns Hopkins Education and Research Center
Continuing Education Program
615 North Wolfe Street, Room W7517
Baltimore, MD 21205
Please fill out the registration form and submit via:
1) Email to [email protected]
2) Fax to 410-614-4986
3) Mail to ATTN: Keith Choi, Johns Hopkins Education and Research
Center, 615 North Wolfe Street, Room W7517, Baltimore, MD 21205
*Please save a copy of
this form before sending*
EMail Form
Keith Choi
Program Coordinator
410-955-4088 office
[email protected]
Course Title
Course Number
Start Date
Mary Doyle
Director
410-955-0423 office
[email protected]
Exhibitor Fee
Exhibitor Fees (includes 8 ft table, admission for two booth personnel, breakfast, lunch and afternoon snacks):
$500.00 for Vendors
$250.00 for Non-Profit Vendors
Name
Title
Company
Work Address
City
State
Work Number
Zip Code
Email
Fax Number
Method of payment (please check one):
Check (made payable to Johns Hopkins
University)
Credit Card (please check one and complete info below)
American Express
Discover
Mastercard
Visa
Enclosed
In the mail/to follow
Credit Card Information:
Card Number
Print Cardholder's Name
Cardholder's Signature
Expiration Date
Verification Number
*verification number is printed on
signature strip on back of the card.