San Diego Fertility Expo: Exhibit your company or clinic at San Diego's Second Annual

National Infertility Awareness Week
Fertility Expo Registration Form
Please fax back to Reproductive Wellness at (619) 265-0290

NAME OF COMPANY: __________________________________________________

CONTACT NAME(S): ___________________________________________________

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ADDRESS: _____________________________________________________________

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PHONE: _________________________ FAX: ________________________________

WEBSITE: ________________________________ EMAIL: ____________________

BOOTH TOPIC: _______________________________________________________

OTHER COMMENTS: __________________________________________________

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INVOLVEMENT:

GOLD SPONSORSHIP -- $2975
SILVER SPONSORSHIP -- $1475
BRONZE BOOTH –$795

PAYMENT METHOD:

Check (Make payable to Reproductive Wellness)
Credit Card _____ MC _______ Visa ______ AMEX ______ Discover

Card #__________________________________ Exp ___________ CVS # _______

PHYSICIANS ONLY

Please note that all physicians exhibiting at the event must commit an hour of their time to giving 10 minute consultations.

Please choose which level donation you would like to make to the raffle:

One free consultation ($250 value)
Two free consultations ($500 value)
Other ________________________________

Seminar Speaker

Yes, please contact me about speaking at the event during a breakout seminar (30 minutes)

Specialty: _______________________________________________________________

Topic: _________________________________________________________________

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Website, other Bio Information: ___________________________________________

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