2022-2023 Signature Partnership Registration

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2022-2023 Signature Partnership RegistrationCurt Fischer2022-08-19T18:58:38+00:00

2022-2023 Signature Partnership Agreement

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EMERGENCY MEDICINE LEADERSHIP SUMMIT | NOVEMBER 2, 2022
The Conference Center at SeaTac

2023 SUMMIT TO SOUND | May 7-9 Suncadia Resort in Cle Elum, WA

Primary Contact

Primary Contact Name*

First Last Credentials (MD, DO, Etc.)

Primary Contact Job Title

Primary Contact Address*

Street Address Address Line 2 City State ZIP Code

Primary Contact Phone

Primary Contact Email*

Primary Booth Representative Contact

(This information will be published and distributed to attendees)

Primary Booth Rep Contact Information

The contact information for the Primary Booth Rep is the same as the Primary Contact

Primary Booth Rep Name*

First Last Credentials (MA, PhD, etc.)

Primary Booth Rep Job Title

Primary Booth Rep Address

Street Address Address Line 2 City State ZIP Code

Primary Booth Rep Phone

Primary Booth Rep Email*

Representatives Staffing Booth

Representatives

To add more reps, push the + button to the right.

First Name

Last Name

Email

Exhibitor Information

Company Type

Choose all that apply

Billing/Coding Services

Cardiovascular

Computer Software/Hardware

Consulting Services

Diagnostic Products/Services

Documentation Services

EDIS

Educational Products/Services

Emergency Medical Equipment

Imaging/Ultrasound Equipment

Insurance/Risk Management

Market Research

Ophthalmic Products

Orthopedic Products

Patient Monitoring

Pharmaceuticals

Recruiting

Safety

Specialty Products/Services

Software Products

Staffing/Management

Telemedicine

Product/Service to be displayed

Please indicate companies you desire NOT to be located adjacent to (i.e. competitor)

Signature Partnership

Pay in full now ($4500), or pay a 50% deposit now and be invoiced for $2250 in 2023 for Summit to Sound.

2021-2022 Signature Partnership Agreement

Signature Partnership: - $4,500.00

Signature Partnership Deposit: - $2,250.00

Payment Type*

Credit Card

Check

Invoice

Check Number

Coupon

TOTAL

CREDIT CARD

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

INQUIRIES
Contact Cailey Nickerson, Chapter Executive, at the Washington ACEP office at 206-956-3648 or send emails to admin@washingtonacep.org

2001 6th Ave, Ste 2700, Seattle, WA 98121

Phone: (206) 956-3648

Fax: (206) 441-5863

Executive Director: Cailey Nickerson