Participant Registration Form

March 8, 2011

8th Annual

Pioneer Center Provider Fair

Ross Educational Service Center

475 Western Ave.

Chillicothe, OH 45601

4:30 to 7:00 PM

Company/Organization/Group_______________________________________________

Address:________________________________________________________________

City____________________________________________________________________

State________________ Zip Code_______________________________________

Contact Person___________________________________________________________

Contact Person’s Email____________________________________________________

Contact Person’s Phone: Area Code______ ______________________________

Number of Tables Needed (one guaranteed) ____________________________________

Special Needs or Questions:

________________________________________________________________________

Will you be bringing a raffle item for a drawing during the Fair?____________________

Return to:

Dottie Fay, Community Information

Pioneer Center

11268 Co. Rd. 550

Chillicothe, OH 45601

(740) 773-8044

FAX: (740) 773-8052