Exhibitor Application November 2025 PIU

Approval and Authorization for Funding and Participation

By proceeding with this application, I attest that the pharmaceutical company that I represent has reviewed and approved this funding and participation. I am authorized to complete this application on behalf of the sponsoring company.

Company Name

Address (for tax receipt purposes)

Address Line 1

Address Line 2

City

State

Zip Code

Date

Type of Sponsorship

Attending Representative's Name

Phone

Second Attending Representative's (Only for Premier Sponsors)

Company Contact Information for Payment (if different then above)

Phone

Payment Type

Fee Acknowledgment

I acknowledge that by choosing to pay by credit card or invoice, I will be responsible for covering any associated processing fees.

Card type

Name on Card

Card Number

Expiration Date

CVC

Billing Zip

Billing Card Participation

Additional Comments or Instructions

Total Amount

$0.00