Presents the Long Island Practice Summit
March 3, 2019 | Wang Center – Stony Brook University, Stony Brook NY

We have a limited number of tables. To ensure you are represented at the meeting we recommend that you register and pay online.
Please download the Exhibitor Terms Document. It has all of the rules and regulations associated with agreeing to be an exhibitor
To pay by Credit Card and reserve your space CLICK HERE

Exhibitor Form
Company Name_________________________________ Main Contact ___________________________________
Contact Email ___________________________________ Phone _________________________________________
Address _______________________________________ Fax ___________________________________________
City ___________________________________________ Web Address http://_____________________________

State __________________________________________ Email Address __________________________________
Representative 1
Name _________________________________________ Badge Name ___________________________________
Cell Number ____________________________________ Email Address __________________________________
Representative 2
Name _________________________________________ Badge Name ___________________________________
Cell Number ____________________________________ Email Address __________________________________

Fees
Exhibitor Registration includes registration for 2 representatives, display table, Electricity at display table and post conference attendee list
Exhibitor Tables Fee
☐ Exhibitor (before December 1, 2018) $800
☐ Received after Dec 1 but before Feb 1, 2019 $1,000
☐ Received after Feb 1, 2019 $1,200

Educational Grants
☐ Non CECH Event
Includes
recognition that you supported the event
you provide the speaker for the program.
☐ $1,200 to support speaker
☐ $1,800 to support 2 speakers

☐ Continental Breakfast $1,000
☐ Morning Coffee Break $1,000

☐ Lunch
Includes
link on conference web site,
pre conference attendance list,
signage at lunch
recognition in conference documents.
$2,500

☐ Afternoon Coffee Break $1,000

☐Platinum Support (1 available)
Includes
link on conference web site,
pre conference attendance list,
signage at conference and recognition in conference documents
2 tables in exhibit area.
The ability to provide bags and name tag lanyards for every attendee.
$4000

☐Gold Support (3 available)
Includes
link on conference web site,
signage at conference and recognition in conference documents
1 insert in the attendee bag.
$2,000

Total
Payment Type: ☐ Check ☐ Visa ☐ Mastercard ☐ American Express
Name on Card ___________________________________ Card # _________________________________________
Billing Address __________________________________ Expiration Date __________________________________
Billing City ______________________________________ CVV ___________________________________________
Billing Zip ______________________________________ Total __________________________________________
Signature _______________________________________ Date __________________________________________

Please return form to CME Online P. O. Box 674 Southold, NY 11971 or fax to (631) 547 1423