Senator Langerholc Dubois Senior Expo

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Organization Name (For Program Booklet)(Required)

Exhibitor's Name(Required)

Organization Mailing Address (For Program Booklet)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone # (For Program Booklet)(Required)

Email (Used for Confirmation)(Required)

Enter Email Confirm Email

Please add a short description of your organization for Senior Expo Program Booklet(Required)

Please limit to 250 characters or less

Exhibitor Space

The information below will help us determine your needs for your space.

If you require more than one CHAIR that is provided, how many TOTAL chairs do you need?

Please tell us how many chairs you need for your exhibit, 1 is provided, if you need 4, please tell us 4.

Do you need a tablecloth for your exhibit table?(Required)

Check One - My exhibit, when placed upon a table, is higher than 3 feet.(Required)

Check One - I/We will require Electric. (Electric is very limited)(Required)

Check One - This organization is a non-profit (501c3) or governmental agency(Required)

I/We will be providing a healthcare screening.

If Yes, describe health screening.

Does your organization accept Medicare and/or Medicaid?(Required)