Vendor Registration – Healthy MS Conference

VENDOR REGISTRATION

Please make your selection and return this form no later than May 15th, 2023, along with your
check made payable to:

Mississippi State Department of Health Office of Preventive Health, C/O Charlotte Holly, P.O. Box 1700, Jackson, MS 39216-1700

CONTACT US: Phone 877-673-2462 • Fax 877-673-2462 • Email info@healthymsconference.com • Website www.healthymsconference.com

Name *

First

Last

Organization/Business

Address

Address Line 1

City

State

Zip Code

Layout

Phone

Website

Name of Person Attending Conference *

First

Last

Name of Person Attending Conference

First

Last

Upload Company Logo

Click or drag a file to this area to upload.

Vendor Fee *

Vendor (Selling Items) - $ 150.00
Community Organization Nonprofit - $ 0.00

Please describe the type of goods/services you will provide at the event.

We must receive all payments and forms in the mail by April 15th.

Stripe Credit Card

Card

Name on Card

If you are a FREE VENDOR - please bypass the Credit Card area. If you are a Paid VENDOR and do not pay by credit card during registration, your registration will not be accepted. If you have any issues, please contact the conference planner with any questions at healthymsconference@gmail.com or call 1-877-67-ECHMC

Total

$ 0.00

Please make your selection and return this form no later than May 15th, 2023, along with your check made payable to:

Please make your selection and return this form no later than May 15th, 2023, along with your
check made payable to: