REQUEST FOR EXHIBIT SPACE

CONTACT NAME ORGANIZATION/COMPANY NAME MAILING ADDRESS CITY PHONE FAX STATE EMAIL ZIP ______ ______

I am interested in exhibit space for the upcoming 9th Annual Statewide Conference on Sexual Assault and Family Violence, being held at the Baton Rouge Marriott, November 27-29, 2012. Space is limited and is available on a first come, first served basis. Booths may be set up starting at 8:00 a.m. on Tuesday, November 27th. The cost of exhibit space is as follows: Conference Sponsor (no charge) Non-profit agencies - $100 For-profits - $250 TOTAL REMITTED $ Payment by: ___ check or money order payable to LAFASA ___ charge the exhibit fee to my Visa, Mastercard or Discover: Card Name: ______________________________________________________________ Acct. #_________________________________________ Exp. Date ________________ I intend to sell exhibit the following items:

Signature MAIL COMPLETED FORM WITH PAYMENT TO: Mariah Stidham Wineski LAFASA Director of Education 1250 SW Railroad Ave., Ste. 170, Hammond, LA 70403 Phone 985-345-5995 * Fax 985-345-5592 * Mariah@lafasa.org

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