2016 Fall Special Education Conference Exhibit Request Form Question Title * 1. Organization Contact Information: Name: * Company: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title * 2. Representing us at the conference will be: Name: Address: Address 2: City/Town: State: ZIP: Email Address: Phone Number: Representative 1: Representative 2: Question Title * 3. Please reserve our company a booth. We request that the following number of booths be reserved: Question Title * 4. We will need an electrical outlet: Yes No Question Title * 5. We will provide a doorprize: Yes No Question Title * 6. Tell us how your exhibit relates to Oregon Special Education (200 words or less). If selected, we will put this information in the conference program. If you are selected you will be billed $500 (per table) for the requested exhibit space. COSA will not be responsible for the safety of the property of exhibitors from theft, damage by fire, water, storm, vandalism, or other causes, but will take reasonable precautions to protect the exhibitors from such loss. Done