Registration Form

Thank you for your interest in the annual 2011 Employee Health and Wellness Fair. Please complete the secured fields below. If you would prefer to mail in a registration form, a printable copy is available for download here: Registration Form (.pdf)

Once you submit your Registration Form we will contact you with more event details, including parking information. If you have any questions please contact Sharlene Lascelles, Human Resources, at 315-361-7893. Our fax number is 315-361-7902.

Company/Organization Name: *

Name/Contact Person: *

Email Address: *

Mailing Address: *

Address 2:

City: *

State/Province: *

Zip Code: *

Office Phone: *

e.g. (555) 555-5555

Other Phone:

e.g. (555) 555-5555

What Products or Services does your company provide in the Health, Safety and Wellness industries?: *

Will your company/organization be interested in providing any demonstrations, screenings, testing, etc?: *

Yes

If yes, please provide details (i.e. type, description, duration, content, AV or electrical needs, etc). We will contact you regarding scheduling. Also, please note all demonstrations will be displayed on a large TV screen.:

Who from your company/organization will be attending:

Do you plan to have products available for sale? : *

Yes

Extra Tables: *

Yes

*Please note that extra tables are $7 each

If yes, how many tables:

Electrical Outlets: *

Yes

If yes, how many electrical outlets:

Lunch Buffet: *

Yes

Lunch Buffet is available from 11:30 a.m. - 2:30 p.m.

If yes, how many will be dining:

Are you a Non-Profit Organization?: *

Yes

If yes, please enter your current Non-Profit Tax Exempt ID number:

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math question: * 19 + 0 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.