Exhibitor Application Form Exhibitor Agreement* I agree to the statement below. I the undersigned, apply for technical exhibit space at the Florida Society of Anesthesiologists Annual Meeting to be held June 8-10, 2018 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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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 Fees*BOOTH 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. Priority Booth-$2,650Standard Booth-$2,150Standard Booth-$1,000Total $0.00 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: firstname.lastname@example.org Credit Card* American ExpressMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.