Scanner Request Form

Company Name(Required)

Please enter your company name as it should appear on all meeting materials including the INA website, banners, conference app, etc.

Company Type(Required)

Pharmaceutical/Device

Non-Profit

Other

Other Company Type(Required)

Please specify your company type

Contact Name(Required)

First Last

Contact Title(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cell Phone(Required)

Phone

Website

Handheld Scanners(Required)

Please select the quantity of handheld scanners you would like to rent.

1 Scanner - 250 USD

2 Scanners - 400 USD

Upon submitting your request, you will receive a PDF to review, sign and return to exhibits@neurotoxins.org.

Once the request has been approved and co-signed you will receive an invoice and the co-signed request. Payment can be made by check or wire transfer. There is a 35 USD charge for wire transfer.

Please indicate how the invoice for payment should be processed(Required)

Check

Wire Transfer (+ 35 USD)

I will provide a PO number(Required)

Yes

Applicant Full Name(Required)

Please enter the name of the person in your organization that will provide an authorized signature.

Scanner Request Form

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