2012

Convention
Sponsored by
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HOTEL INDIGO
1830 W MAIN STREET
RIVERHEAD, NEW YORK

I would like to participate in the deal-making at

The Tailgate Convention
_____$ 50 Chamber Member Fee

Payment Information
Master Card

Visa

AMEX

Check

Credit Card #:_______________________________

Expiration Date (mm/yr)__ _/__ __

_____$100 Non Chamber Member Fee

*includes listing in the deal-makers catalog.
Contact Information:

CVV2 Code:___________
Card Holders Information
Name: ______________________________________

Business Name _________________________________

Category ______________________________________
# of Years in business ___________
Your deal _ ____________________________________
________________________________________________
*Participants must bring at least 100 business
cards, brochures or samples.

Billing Address_______________________________
City, ST _________________________Zip__________
Phone_______________________________________
Email________________________________________
Total $_____________________
Authorization Signature
_____________________________________________

Fax this form to: 631-727-7946 or mail it to Riverhead Chamber 542 East Main Street, Riverhead, NY 11901
Register online at www.riverheadchamber.com