Senior Citizens Expo Exhibitor Registration Form

Thank you for your participation in our upcoming Senior Citizens Expo. Your attendance is vital to the success of this event!

For questions or additional information, please contact Suzan Paisley at the Coudersport office at 814-274-9769 or by email at spaisley@pahousegop.com.

Organization Name *

Mailing Address *

City *

Zip Code *

Phone *

Website Address

Email Address *

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Please select the expo which you plan to attend: *

Roulette: Friday, Oct. 13

Please check all the appropriate boxes that pertain to your organization.

I will bring a door prize.
I will need an electrical outlet and I will bring my own extension cord.
Please contact me about sponsoring these expos with a donation.
My organization will host a health screening.

If hosting a health screening, describe screening type

First Name *

Last Name *

Phone *

Email Address *

Leaving this box checked verifies that you would like to receive legislative email updates.