Market Place Spaces

Georgia Dental Hygienists Association (60445)
Market Place Registration
Georgia Center for Continuing Education
Athens GA 30602-3603
Fax: 706.542.6596 or 1-800-884-1419
 

________________________________________
Name of attending representative		 _____________________________
position 		_______________________
Date of Birth

________________________________________
Preferred name for name badge		  
_____________________________________________________
organization (to be listed on Market Place/display sign)

____________________________________________
Business mailing address (check here if home address _)

____________________________________________________
City state zip county, if Georgia

_____________________
Work phone 
________________________
fax
_______________________________
e-mail address

Market Place/Display Fees:
Market Place space ____________ x 40.00 = $_________

Total Fees Due: $_____________

Method of Payment to reserve your exhibit/display space:
_ Check (payable to The University of Georgia) _ MasterCard _ Visa _ American Express _ Discover
Card # Expires ___/___Name on Card Signature