TLPCA Counseling and Therapy Summit Exhibitor Registration & Other Options "*" indicates required fields Exhibitor Registration ItemsName of Organization (as it will appear in the conference program):*Name of Contact Person to Receive All Exhibit Information:*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Business/Organization Website* Provide a business/organization description for the conference program.*File or Graphic for promotional purposes:* Drop files here or Select files Max. file size: 29 MB, Max. files: 3. DISCLAIMER* I agree.TLPCA does not provide a list of registrants or attendee contact information as part of any exhibit or sponsorship packages. Levels of Support and ParticipationExhibitor Options* Exhibit Table (with two (2) Summit registrations) - $700 Exhibit Table (with one (1) Summit registration) - $500 Exhibit Table (without Summit registration) - $350 None of the above Additional Options* Bag Inserts $400 Full page ad in program book $300 Half page ad in program book $200 Quarter page ad in program book $150 None of the above Contact the conference coordinator at executivedirector@tlpca.net to make arrangements for your promotional item.Complimentary RegistrationsPlease provide the names of ALL of the complimentary conference attendees below, including yourself.Name of Person 1 to receive complimentary registration* First Last Email of Person 1 to receive complimentary registration* Enter Email Confirm Email Name of Person 2 to receive complimentary registration* First Last Email of Person 2 to receive complimentary registration* Enter Email Confirm Email Payment InformationTotal Coupon Payment Option* Check Credit Card Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentsThis field is for validation purposes and should be left unchanged. Δ Annual ConferenceRegistration & Payment Summit General Info Schedule Keynote Location Hotel Information CE Information Call for Proposals Sponsors & Exhibitors Opportunities Sponsor Registration Exhibitor Registration & Other Options