"*" indicates required fields How would you like to pay for your vendor registration?* Pay by Credit Card Pay by Check Company InformationOrganization Name* Primary Contact's Name* First Last Primary Contact's Phone*Primary Contact's Email* Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Vendor LevelsVendor level*Choose your vendor levelDiamond ($3,000)Ruby ($2,000)Sapphire ($1,500)Emerald ($1,000)Attendee InformationAttendee 1: Name First Last Attendee 2: Name First Last Attendee 3: Name First Last Attendee 4: Name First Last Attendee 5: Name First Last Additional AttendeesDo you want to register additional attendees? Yes No Additional Attendees Quantity Price: $150.00 Quantity Additional Attendee Names*Pay by CheckPlease make checks payable to “FLA-PAC” Checks should be mailed to: FLA-PAC Office of the Treasurer Attn: Christa Wisniewski PO Box 9507 Fort Lauderdale, FL 33310Total Amount Due:Credit Card Billing InformationTotal Credit Card Δ
