"*" indicates required fields Exhibitor Agreement* I agree to the statement below. I am applying for technical exhibit space at the Florida Society of Anesthesiologists Annual Meeting to be held June 6-8, 2025 at the Breakers in Palm Beach, Florida. I agree to accept the conditions, rules, regulations, terms and policies in the Exhibitor Prospectus which form part of this agreement.Exhibitor InformationPlease indicate company information exactly as it should appear in all official publications.Company Name*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Company Phone*Company WebsiteContact InformationPre-Show Contact Name* First Last Pre-Show Contact's TitlePre-Show Contact Phone*Pre-Show Contact Email* Please indicate the products or services you will display:Booth Assignment:Booths will be assigned at the sole discretion of show management and will be based on the date of request and consideration of competition. There are a limited number of priority booths available. No specific booth guarantees will be made until payment is received.Please indicate which companies should not be placed in close proximity to your booth location, FSA will attempt to recognize this request in booth placement, but cannot provide any guarantees:Booth FeesBOOTH FEES INCLUDE: 8'x10' booth space, 8 ft. back wall, 3 ft. side walls, one 6 ft. draped table, two chairs, one waste basket., one exhibitor ID sign. Priority booths are in high visibility locations. Early Bird Deadline: March 21, 2025 Priority Booth-$2,650Standard Booth-$2,150Booth FeesBOOTH FEES INCLUDE: 8'x10' booth space, 8 ft. back wall, 3 ft. side walls, one 6 ft. draped table, two chairs, one waste basket., one exhibitor ID sign. Priority booths are in high visibility locations. Early Bird Deadline: March 21, 2025 Priority Booth-$2,800Standard Booth-$2,300This field is hidden when viewing the formToday MM slash DD slash YYYY Total Payment Method*CardCheckPlease make check payable to the Florida Society of Anesthesiologists and send to: FSAHQ, Attn: Jenay Root 11300 W. Olympic Blvd. Suite 600 Los Angeles, CA 90064 For more information, please contact Jenay Root EMAIL: [email protected] Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.
