Registration

Presenting Company Registration
Capital Conference
7a.m. to 2p.m.

PRESENTING COMPANY:
Company Name:
(Company name and address must match exactly the way your Company is listed with the SEC, incorporated or organized)
Address:
City: State: Zip:
Country: Website:  email:
Toll Free #:             Other:    Fax:
Public Exchange It Trades On:    Symbol: Public Offering: Private Company:
Sector:       Industry:
SCIA MEMBER SPONSOR:
Name of Your Sponsor: Sponsor’s Phone:

List Main Management First:
1. Main Executive Name: Title:
Main Executive’s Cell : Email:
2. Second Representive Name: Title:

Second Representative’s Cell: Email:

PRESENTING COMPANY FEES:(Due upon application to reserve your presentation date)

All Fields Must Be Completed

INAUGURAL BASIC FEE: $7500.00

ADDITIONAL COMPANY MANAGEMENT/REPRESENTIIVE’S: Add $70.00 per person

3. Name: Title:
4. Name: Title:

$600.00 to host the cocktail reception hour before the luncheon. SCIA will promote you immediately and exclusively. This is inexpensive and a good opportunity for extra promotion of your Company before the luncheon.
TOTAL FEE DUE UPON APPLICATION TO RESERVE TIME SLOT: $

Electronic Signature: Must be Clicked to Process Registration and all Funds:

Corporate Overnight Check to SCIA is Preferred to: SCIA, 1278 Glenneyre Street #19, Laguna Beach, CA 92651

Company Check Overnight Check #

AMEX VISA MC Discover Excepted. Call 949-922-3003 to Process Payment

Cardholder