Company Name *

What Resource(s) will you be providing?
(Select all that apply)
County ServicesEducationFood AssistanceDental / Medical / VisionHousingLBGTQLegal / ExpungementMental Health / Substance InterventionTransportationVeteran Service OrganizationsWomen’s HealthOther

Company Street Address *

Zipcode *

City *

State *
AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming

First Name *

Last Name *

Phone *

Email *

Booth Accommodations

Our tables come with one (1) 6ft. table and two (2) folding chairs. The following questions will help us accommodate you if you have any additional needs for your booth.
Do you need electrical?
YesNo
Do you need additional chairs?
None1234
Do you need additional tables?
None12
Do you have a mobile unit?
YesNo
(If Yes, please specify size of mobile unit and if you have a generator in "Additional Information")

Please provide any additional information: (Max:1,000 characters)

How did you hear about this event?
—Please choose an option—TVRadioOnlineNewspaperWork Source Center (AJCC)Employment Development Department (EDD)Friend / FamilyOther

I Agree *
By checking this box and clicking Submit below, you agree to ALL Terms and Conditions. Registration is not a confirmation for attendance. Once confirmed you will be receiving a confirmation letter with follow-up instructions, including parking.