Individual Registration

Please enter information in the form below to process registration for event 2021 WIPSCOM Conference Vendor Registration.

First Name *

Last Name *

Agency *

City, State, Zip *

Phone

Email of Registrant *

Number of extra vendors in booth

• N/C

• 1(+50)

• 2(+50)

• 3(+50)

• 4(+50)

Names and Titles

Vendor Sponsorship Opportunities

• Conference Materials (Any Amount)

• YAPP App ($500)

• Conference Pins ($750)

• Bronze Level ($1500) - Break Room

• Silver Level ($2500) Breakfast

• Gold Level ($3500) Keynote Speaker

• Platinum Level ($5000) Lunch in the vendor hall

LOGO

Payment Information

Amount

$

Discount Amount

$

Gross amount

$

Payment Method *

Offline Payment Credit Card Payment

Billing Zipcode*

Credit Card Number*

Expiration Date*

01 02 03 04 05 06 07 08 09 10 11 12 / 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

Card (CVV) Code*

Card Type*

Visa MasterCard Discover American Express

Card Holder Name*

Verification code*

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Username

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