<p> WEST TEXAS A&M UNIVERSITY AND REGION 16 EDUCATION SERVICE CENTER PANHANDLE MATH AND SCIENCE CONFERENCE July 26 - 27, 2016</p><p>EXHIBITOR REQUEST FORM</p><p>Name of Organization ______</p><p>Contact Person ______</p><p>Phone ______E-Mail Address ______</p><p>Please mark the appropriate selection(s) below: _____Our Organization will provide an exhibit at the Conference on July 26th and 27th. _____We will provide speaker(s) for Conference sessions. A Speaker Proposal Form will be posted at www.wtamu.edu/pmsc. _____We will bring door prizes for participants</p><p>If you plan to provide an exhibit, please complete the following information: _____ Platinum level sponsor ($500): FaceTime at lunch to speak about your product/services, Priority placement for up to four exhibitor tables, Large icon on poster, Full Page PowerPoint slide during lunch both days, Two lunch tickets for each day.</p><p>_____Gold level sponsor ($300): Quick company introduction at lunch, Up to three exhibitor tables, Medium size icon on poster, Half Page PowerPoint slide during lunch both days. Two lunch tickets for each day.</p><p>_____Silver level sponsor ($200): Up to two exhibitor tables, Small size icon on poster, Listed on PowerPoint slide. Two lunch tickets for each day.</p><p>_____Bronze level sponsor ($100): One exhibitor table. Two lunch tickets for each day.</p><p>_____Exhibitor only ($40): One exhibitor table (Does not include lunch tickets but may purchase below)</p><p>_____Non-Profit Organization: No charge for one exhibitor table (Does not include lunch tickets but </p><p> may purchase below)</p><p>We need ______additional lunch tickets at the cost of $20/two day ticket. (How Many?) We need ______chairs for our exhibit. (How Many?)</p><p>Do you need electrical outlets for your exhibit? YES NO (EXTENSION CORDS WILL NOT BE PROVIDED!)</p><p>TOTAL AMOUNT OF CHECK ENCLOSED: $______(Please make checks payable to WTAMU PMSC EXHIBIT.)</p><p>For questions contact: Dr. Carolyn Bouma email [email protected] or call 806-651-2569 Mary Jane Cruz email [email protected] or call 806-651-2537</p><p>Please return this form and appropriate fees no later than June 30th, 2016, to: Department of Chemistry & Physics; WTAMU Box 60732; Canyon, TX 79016</p><p>NOTE: Your Form is not “RECEIVED” (or your space assigned) until required fees are paid.</p>