Empower Her Wellness Summit Vendor Registration Form Empower Her Youth Wellness Summit Vendor Registration Form Business or Organization Name(Required) Vendor Contact(Required) First Last Phone(Required)Email(Required) Website(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Primary Product/Service Category Mental Health Food & Beverages Other Will you need a table and two chairs?(Required) Yes No Years in business(Required) Tax ID Number Please list any dietary considerations for anyone operating your booth. Agreement Yes No I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that I have the option of bringing a gift card/basekt with a value of $25 for the raffle. I understand that providing false information may result in termination of any subsequent agreements between Bastrop County Cares and the undersigned vendor.Please select your business type.(Required) Food Manufacturer Wholesaler Retailer Service Provider Nonprofit Other Total Payment Method(Required)PayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.
