This document is a registration form for exhibitors to register for one or multiple event locations of a conference put on by the Southern California Chapter of the PDA. It provides payment options to pay by check or credit card, and requests the exhibitor's contact information as well as payment amount and credit card details if paying by card.

1. CHECK OR CREDIT CARD
Exhibitor Name:
Title:
Company:
Business Address:
City / Sate / Zip:
Business Phone:
Fax Number:
Email Address:
Event Locations: SD- Genentech/Roche OC-Allergan LA- Grifols Biologics
Exhibitor: $150.00, for one location (includes: 1 attendee, additional attendees
must use regular registration form)
$400.00, for three locations (includes: 1 attendee for each location,
additional attendees must use regular registration form)
Mail Check Payments Payable to:
Southern California Chapter of the PDA
Attention: Brian Underhill, BioSPEQ/PDA- 3200 El Camino Real, Suite 230, Irvine, CA 92602
For Visa, MC, or American Express Payments, email completed registration form to PDA, Stephanie
Powers Kurtz at spowerskurtz@sterile.com . Incomplete forms will not be processed.
Name as it appears on credit card: _____________________________
Total to be charged on card: $_____________
Credit Card Billing Address: _______________________City: _________State: Zip Code:
Card Number: _____________________________Expiration Date: ___________
Signature: _____________________________ Date: _______________