Exibitor Staff Registration Form

Four Ways To Register: Please print this page, fill out form, and submit by February 14, 2005
Email:	joanne.moreno@csun.edu
Phone:	(818) 677-2578
Fax:	(818) 677-4929
Mail:	Attn: Exhibits Coordinator CSUN, Center on Disabilities 18111 Nordhoff Street Northridge, CA 91330-8340

SECTION A(Please list address of where you would like correspondence sent)

First Name: ________________________________________________
Last Name: ________________________________________________
Organization: ______________________________________________
Street Address: _____________________________________________
City: ______________________________________________________
State/Province/Region: _______________________________________
Zip/Postal code: _____________________________________________
Country: ___________________________________________________
Day Phone: ________________________________________________
Fax: _______________________________________________________
Email: _____________________________________________________

The Center on Disabilities provides contact data (names and mailing addresses) to third parties who wish to promote relevant products, services and other opportunities which may be of interest to you.

_____ Check here to remove your information from this list.

SECTION B

I AM:( check all that apply)

____	Staffing the exhibit booth ONLY. Booth #: ________(no fee for staff manning booth only)
____	An Exhibitor and Speaker (If speaker registration fee has been paid, there is no additional fee)
____	An Exhibitor attending the General Sessions only (does not include Preconference Workshops) at no additional cost as per booth waiver (maximum of 4 people per booth area; 16 people per island).
____	An additional Exhibitor required to pay the regular conference fees to attend sessions. PLEASE COMPLETE SECTION C.
____	An Exhibitor attending Preconference Workshops. PLEASE COMPLETE SECTION C.

SECTION C

FEE SCHEDULE	Discounted Fee	Regular Fee	Total Fee
*Additional Fees (Check all that apply)*
Preconference Workshops of Monday, March 14, 2005 Check ONE: __A __B __C __D __E __F __G __H __I	$249 Paid by Feb. 14, 2005	$279 Paid after Feb. 14, 2005	$_____
Preconference Workshops of Tuesday, March 15, 2005 Check ONE: __J__K __L __M __N __O __P __Q __R __S	$249 Paid by Feb. 14, 2005	$279 Paid after Feb. 14, 2005	$_____
_____General Sessions Conference Package Includes all the activities of March 16 - 19, 2005: Keynote Address, more than 300 General Sessions, and entrance into the Exhibit Hallsany time during exhibit hours. (Does NOT include Preconference)	$399 Paid by Feb. 20, 2004	$449 Paid after Feb. 20, 2004	$_____
Total Registration $______

Accessibility Services:

__ Assistive Listening Device
__ Real-Time Captioning (CART)
__ Sign Language Interpreter
__ Adapted Program (check one):__Braille __Disk(ASCII) __Large Print __DAISY CD

There is no fee for authorized care providers accompanying paid attendees.
Care Provider attending with me: (first name, last name) _________________________________

Method of Payment:

Full payment must be received at CSUN no later than February 15, 2005 to qualify for the discounted speaker rate.
Please make check payable to CSUN.

__ Check enclosed for $__________________

__ Charge to my: __MASTERCARD __VISA __AMERICAN EXPRESS

Card #________________________________________ Expiration Date _______________

Card Holder Name(print): __________________________________________________

Signature: ________________________________________________________________