Application for Booth Space at North Mississippi Senior Expo 2011

May 6, 2011 - 9am-2pm

By signing this form, you are agreeing to participate in the North Mississippi Senior Expo 2011.

Please complete, sign and mail this application along with your payment to:

                                                        LifeStyle Transitions

                                                         P.O. Box 4

                                                         Nesbit, MS 38651

                                                         Attention: Susan East

                                    Phone:  (901) 482-0018   Direct Fax: 901-435-0750

                                    Application Deadline is Wednesday March 30, 2011

 Business Name as it appearS in brochure: ____________________________________________________________________Business Name as it appears
on check:  ____________________________________________________

 Describe Your Business:  ____________________________________________________________________

 _____________________________________________________________________Print
Contact Person First Name: ___________________ Last Name: ________________

Street Address: _____________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number: _________________         Fax Number:  ______________________

Email Address: ________________________________________________________________

Number of Electric outlets needed (applicant charge $20 each): _______________________

 Authorized Signature: _________________________Date: ______________
Please Indicate:

Non-Profit booth $150 – outlet extra $20 ________________

 Exhibitors booth $250   - outlet extra $20 _______________

                                    Expo Member                            Premium Member (Sponsor)

                                     $349 per year                                         $849 per year

                                 *includes Senior                                    * includes Senior

                                     Expo Booth                                            Expo Booth