2018 Fellows Spring Practicum Exhibit Space Contract

SIR

Company Information

(The information listed in the section will appear in all official SIR publications.)

Company Name

Address

City

State

Zip Code

Country

Exhibitor Contact Information (who will receive exhibit materials and is official representative)

Contact Name

Contact Title

Address

City

State

Zip

Country

Phone

As an authorized representative of the above stated exhibiting company, I confirm that I am authorized by my company to make such commitments on its behalf.

Authorized Signature

Title

Exhibit Fees/Payment Total

Product to be Displayed:

Exhibit Fees

Payment Total

Payment Method

Make checks payable to Society of Interventional Radiology in U.S. funds drawn on a U.S. bank.

For credit card payments, contact Susie Evenden at (703) 460-5586.

Payment Address:

Society of Interventional Radiology

Attn: Exhibits Manager

3975 Fair Ridge Drive, Suite 400 North

Fairfax, Virginia 22033

Phone: (703) 460-5586 Fax: (703) 691-1855

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