Exhibit Representatives Company InformationCompany Name*Phone*Conference Coordinator's Name* First Last Conference Coordinator's Email* Attending RepresentativesDo you plan to have more than 2 representatives attend?* Yes No If you plan to have more than 2 representatives attend, you can add additional representatives for $500 each.Additional Representatives Quantity* Price: $500.00 Quantity Attending Representative 1's Name First Last Rep. #1 Email* Attending Representative 1's TitleAttending Representative 2's Name First Last Rep. #2 Email* Attending Representative 2's TitleName, Email and Titles of Additional RepresentativesPayment and TermsTotal $0.00 How would you like to pay?* Credit Card Check Credit Card*Card Details Cardholder Name Please make checks payable to Georgia Vascular Society, Inc. Tax ID# 45-4588488 Mail to: Georgia Vascular Society, Inc. c/o Burkhardt Planning & Consulting Attn: Liz Sullivan-Burkhardt, Executive Director 3439 Vestal Parkway East #238 Vestal, New York 13850Consent* WE AGREE to abide by the Rules & Regulations.
