Washington State Urology Society

Exhibitor Request Form

WSUS Annual Conference
June 19 – June 20, 2010
Sleeping Lady
7375 Icicle Road
Leavenworth, WA. 98826
www.SleepingLady.com
• Please complete and fax your company exhibitor request form to WSUS 360-668-4053
• All payments must be received by June 1st in order to be guaranteed a listing in the attendee handout
material.
• This program is being advertised to urologists and office administrators primarily in WA, OR, ID, AK.

Name (primary company contact)_________________________________________________________

Company_____________________________________________________________________________

Address_______________________________________________________________________________

City___________________________________________________State________Zip________________

Phone___________________________________Fax__________________________________________

E-mail address
(required)_____________________________________________________________________________

List of Company Representatives attending the meeting:

1) ___________________________________ email______________________________

2) ___________________________________ email______________________________

3) ___________________________________ email______________________________

Our Company plans to support the WSUS Annual Program:

A 6 foot exhibitor table display ($1000)

□ We will need an electrical outlet

□ We will NOT need an electrical outlet

Washington State Urology Society

Tax ID# 91-1246792

914 164th St. SE, Suite B-12 #244 Mill Creek, WA 98012
djmgmt@earthlink.net 360-668-4053 fax 425-971-5822 mobile