Senator Culver Senior Expo Registration

Email

This field is for validation purposes and should be left unchanged.

Organization Name (For Program Booklet)(Required)

Exhibitor's Name(Required)

Organization Mailing Address (For Program Booklet)(Required)

Street Address Address Line 2 City State ZIP Code

Phone (For Program Booklet)(Required)

Email (Used for Confirmation)(Required)

Enter Email Confirm Email

Please add a short description of your organization for Senior Expo program booklet.(Required)

If you require more than the one chair that is provided, how many TOTAL chairs do you need?

Please tell us how many chairs you need for your exhibit, 1 is provided, if you need 4, please tell us 4.

Please tell us if you need a tablecloth for your exhibit.

Check One - My exhibit, when placed upon a table, is higher than 3 feet.(Required)

Check One - I/We will require an electrical outlet. Electricity on site is very limited and is not guaranteed.(Required)

Check One - This organization is a non-profit (501c3) or governmental agency(Required)

I/We will be providing a healthcare screening.

If Yes, describe health screening.

Do you accept Medicare/Medicaid?