Form Test Company Name* Company Representative Name* Representative Title* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Brief Description of Business*Phone*FaxEmail* Website Type of Membership for General Registration* TSMSDC Certified MBE - $300 Corporate Member - $500 NMSDC MBE Affiliate - $400 NMSDC Corporate Affiliate - $700 Government / Non-Profit - $300 MBE Non-certified - $500 Corporate Non-member - $800 Booth Only - $200 Test - $1 Price includes 2 Lunch Tickets, and one 10x10 booth. Marketplace attendance is free.Luncheon Tickets PriceLuncheon Tickets - $55 eachPlease enter a number less than or equal to 99.Please enter a value less than or equal to 99. Registration includes 2 Luncheon Tickets, please enter only ADDITIONAL luncheon tickets.Luncheon Table of 8 - $400 Yes No ListOther Attendees Names Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name
