The 2016 Chesapeake Educational Seminar
“Current Topics in Safety, Health & Environmental Issues”
http://www.jhsph.edu/erc/chespdc.html
Presented by
The American Society of Safety Engineers Chesapeake Chapter and
The American Industrial Hygiene Association Chesapeake Section together with
The Johns Hopkins Education and Research Center for Occupational Safety and Health
Thursday, April 21, 2016
Johns Hopkins Applied Physics Laboratory Kossiakoff Center
Laurel, Maryland
8:00 AM to 4:15 PM
Exhibitor/ Sponsor Registration Form
All exhibitors/ sponsors will be highlighted in the Chesapeake AIHA newsletter, the Chesapeake ASSE
newsletter, and the Chesapeake ASSE website.
Please check all boxes that apply:
____ Exhibitor (includes 2 conference attendees, display table or space for booth, logo)
$350.00.
____ Lunch Sponsor (includes name in brochure, signage with logo at lunch)
$300.00.
____ Breakfast Sponsor (includes name in brochure, signage with logo at breakfast)
$200.00.
____ Break Sponsor (includes name in brochure, signage with logo at break)
$200.00.
____ Contributor (includes name in brochure)
$100.00.
COMPANY INFO:
Attendee Name 1: _____________________________________
Attendee Name 2: _____________________________________
Company Name: ______________________________________________________________
Address: ____________________________________________________________________
Email for confirmation: _____________________________
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Phone: ___________________
PAYMENT INFO:
Check: Make checks payable to “Johns Hopkins University” (Please do not send cash)
Mail completed form and check to:
ATTN: Keith Choi
Johns Hopkins Bloomberg School of Public Health
615 N. Wolfe St., Room W7517
Baltimore, MD 21205
Credit Card: ___Visa ___ MasterCard ___ Discover ___ AMEX
Name on Card (print) ________________________
Signature__________________________
Card Number _____________________________________________
Exp. Date __________
Fax completed form to Keith at 410-614-4986. This is a secure fax machine.
or
Email Completed Form to Keith at [email protected]
Or
Call Keith at 410-955-4088 to pay over the phone.
Total Amount Enclosed or Charged: $ ______________________
Total Attendees: __________
*Please include your email address on the registration form. A confirmation letter and receipt of
payment will be emailed once your payment is processed.
If you have any questions please contact Keith Choi at (410) 955-4088 or email [email protected] .
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