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: _______________