Event Registration - Excelen Events

Contact Information

Course Contact Name/Title *

Company (required)

Enter company/organization name

Course date

Billing Address *

Billing Address

Line 1

Line 2

City

State/Province

Zip/Postal

Course Contact Phone *

Email *

Fax

Cell

Course Information

Date Requested

Enter additional dates here

Start time

:

End time

:

Number of Attendees

Number of Attendees (pricing field) *

Facility Needs

Catering

Quantity served

Time served

:

Special Requests

Veggie

Hot Meal

Equipment

C-arm(s)

1

2

3

More

# of Stations

# Attendees per Station

Shipping

Equipment will be shipped in, disinfected by Excelen and shipped back (Please provide Completed FedEx Labels including account number)

Equipment will be carried in, nothing shipped in.

Audio/Visual Needs

Describe:

Event Registration Cost

General Admission: $21.00

Total Event Cost

Payment

Register!