HealthQuest Registration Form

Company Name:

Contact Person:

Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Please enter booth requirements below:

Number of tables:
Number of electrical outlets:	(bring your own surge protectors)
Number of chairs:
Number of meal tickets:

Will you be bringing a door prize?

Yes No

Type of vendor:

Non-Advertising Vendor (Free)
Advertising Vendor ($60)

Services/Screenings/Information you will be providing:

Other:

Method of payment (if advertising sponsor): Please make payable to "UMHB" and send to:

Debbie Rosenberger, RN
900 College Street, Box 8006
Belton, TX 76513.