Button Chair Request Form

Each • represents required information that is needed to process your application. Be sure to complete all such designated categories.

•	Name of Contact Person
•	Title
•	Affiliation/Organization
•	Mailing Address
•	Physical Address for exhibit placement
•	Telephone (include area code)
	Fax (include area code)
	E-mail
	Dates Exhibit is Needed
	What event will be taking place where the exhibit will be utilized?
	How will event/exhibit be promoted?
	Delivery and Set-up date
	Break down and removal date
	What activities have been planned around the exhibit use (e.g. mammography screenings? Button Chair contest? Fundraiser for local American Cancer Society, etc.?)

	Where will the exhibit be displayed?

	How did you hear about the button chair exhibit?

	How do you plan to evaluate your event?

	Is this an annual event?	Yes No

(Note: Although the Button Chair exhibit is a contribution from the Blue Cross and Blue Shield of North Carolina Foundation, by submitting this application, the contact person agrees to pay for any damages (beyond reasonable wear and tear) incurred while on display at the event site. The installation company will report damages and the applicant will be notified within 5 business days of fees incurred.)

The Button Chair
- Button Chair Request Form