Wellness Bash Exhibitor Form

Exhibitor: Topic/Type *
Screener: Type *
Number of Tables Requested * 1 2
Number of Chairs Requested * 1 2
Number of Exhibitors Exptected to be Present *
How many vehicles will you need to park on campus the day of the Wellness Bash *
Do You Need:
Electrical outlet * Yes No
Student Volunteers to Help with the Screening/Exhibit * Yes No
IF YES: # of student volunteers needed
Other Requests/Information
Please provide the following information:
Organization/Department Name: *
Contact Person/Title: *
Street Address: *
City: *
Zip Code:
State
Phone Number: *
Fax Number:
Email: *
Web Site:
Description of Organization:
Security code: *