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

Name(Required)

First Last

Title(Required)

Address(Required)

Enter the address associated with your credit card.

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

Email(Required)

Cell Phone(Required)

Phone

Handheld Scanners(Required)

1 Scanner - 200 USD

2 Scanners - 400 USD

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

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

On-site Contact

Full Name(Required)

Please add the name, email, and cell number for the contact person who will be responsible to pick-up the scanners on-site.

Email(Required)

Cell Phone(Required)