Clear Form 2015 Innovation Expo Registration Form PLEASE RETURN THIS FORM TO THE MIC OFFICE. IT IS RECOMMENDED THAT YOU KEEP A COPY FOR YOUR RECORDS. Name of Inventor and Co-Inventors 1. Designated Representative IF APPLICABLE 1. 2. 2. 3. 3. Company Name Phone Address City State E-mail Zipcode Website Exhibitor Name Badges (limit 5) A name badge is required for each person in your booth. (Additional badges $5.00 each) 1. 2. 3. 4. 5. 6. (addn'l) Have you exhibited at MIC previously? (Yes / No) If yes, what year(s) did you exhibit? Name of Invention or Business for Booth Sign Invention/Exhibit Description [7"X44"] (Max. 35 characters) (30 words or less - USED FOR MEDIA RELEASES) 1. 1. Is your invention Patented? (Yes / No / Pending) SELECT A CATEGORY FROM THE LIST BELOW THAT BEST DESCRIBES YOUR INVENTION: 2. 2. Is your invention Patented? (Yes / No / Pending) SELECT A CATEGORY FROM THE LIST BELOW THAT BEST DESCRIBES YOUR INVENTION: 3. 3. Is your invention Patented? (Yes / No / Pending) SELECT A CATEGORY FROM THE LIST BELOW THAT BEST DESCRIBES YOUR INVENTION: Categories for inventions (used for judging purposes only) Agricultural Electronics Energy/Environment Industrial Equipment Lawn & Garden Sports & Recreation Transportation/Automotive Other - please specify in box above Health Care/Medical Tools/Construction Household/Personal/Food Toys/Games/Education Type in your QTY and TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Instructions: After completing the form remember to print a copy for your records and send a copy to the MIC office. See below for the address. 0 MAKE A COPY FOR YOUR RECORDS! Declaration and Eligibility statement: By filling in and submitting this form, I state that I intend to be present at the Inspire™ on April 30 & May 1, 2015, in Minneapolis MN, to display my invention or represent my business. I represent that, to the best of my knowledge and belief, the information contained in this entry form is correct and for inventor exhibitors: that my invention is a new, novel invention or a significant improvement of an existing invention. I authorize the MIC to use my name, likeness, hometown and a brief description of my invention in contacting the media, including release on the internet and other electronic media. I will promptly provide additional information reasonably requested by the MIC. Payment Information – please check one of the payment methods below. Check or money order payable to Minnesota Inventors Congress __Credit card information – call me with your credit card information. EXHIBIT BOOTH: (What do you get for your registration fee?) Unless noted, your booth includes an 10’ x 10’ draped booth; one 7" X 44" Booth ID sign, with the name of your invention, used for judging purposes only; a draped 6’ table; and two chairs. It also includes one ticket to the Awards Dinner and Ceremony. A free 1/8 page ad in the Expo Show Guide and a directory listing. Free attendance at any workshop held during the event, on both days. Be sure to order additional meals for the other people in your booth. Only cancellations made by Tuesday, March 31, 2015 will be issued a refund, minus a $50 processing fee. Cancellations received after March 31, 2015 and exhibitors who fail to appear at the show in its entirety will forfeit their fee to the Minnesota Inventors Congress. All cancellations MUST be received in writing. Minnesota Inventors Congress 500 Airport Road Suite 211A P.O. Box 71 Redwood Falls, MN 56283 507.627.2344 or 1.800.468.3681 [email protected] www.inspireexpo.org www.inventorscongress.org