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Lead Retrieval Order Form

MAIL OR FAX THIS FORM TO:

SMART-reg International, Inc.

990 San Antonio Road Palo Alto, CA 94303

Fax:

(650) 565-9300

Hawaiian Eye Meeting 2010

Phone: (650) 565-9200

email: exhibitorservices@smart-reg.com

January 17-22, 2010 Kauai, HI

Order online: www.smart-reg.com/web-reg/sld Show Code: HIEYE10

On or Before

After

After 01/04/10

Qty.

12/18/09

12/18/09

& Onsite

______

$190

$240

$295

Order by December 18, 2009 for the Early Bird Discount!

Desc. SLD-5

Portable, battery powered unit. Leads provided on a USB memory stick.

________

SLD-5P

______

$240

$300

$345

________

Portable, battery powered unit with AC powered printer. Leads provided on a USB memory stick. Printer REQ: 110V power, 1 amp

CA Sales Tax 8.75%

________

Company __________________________________

Booth#

_______

Address

________________________________________________

TOTAL

________

City _______________________________

ST

_______

Zip _______

Contact Name

____________________________________________

Phone

Fax

______________________

________________________

Terms & Conditions

* e - m a i l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C o m p a n y W e b s i t e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Full payment MUST be included with order to guarantee your SMART-Lead-Device.

Sales Inquiry e-mail ________________________________________ *a confirmation receipt will be sent if e-mail address is provided

All credit card orders MUST be signed by the original cardholder.

A $500 security deposit is required on each SLD unit rented. [ ] A check for $_________ is enclosed or [ ] the credit card information below can be used as the security deposit. I understand that the card WILL NOT be charged for the security deposit now, only in the event that the unit is lost, stolen or damaged.

___

Visa/Mastercard

___

AMEX

___

Check (payable to SMART-reg Intl.)

* * C a r d # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Exp. Date

______

Fees collected for unclaimed or unused units are NON-REFUNDABLE.

A $50 processing fee will be applied to any orders cancelled on or before two weeks of published show dates. No refunds will be issued for cancelled orders within 2 weeks of published show dates and/or onsite.

Billing Address

_____________________________________________

C i t y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ST

_______

Zip __________

SMART-Lead-Devices NOT returned within 1 hour of show closing will be charged as NOT returned.

C a r d h o l d e r ' s N a m e

_________________________________________

Signature **SMART-reg International will appear on your credit card statement ________________________________________________

Your order and usage implies you have read, understand and agree to be subject to the detailed terms and conditions as described on the reverse side of this order form.

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