Organization Name*Booth name to appear in syllabus*Type of product or service*Please select from the drop down menuSponsorshipExhibitorName* First Last Title*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone*Language Preference*EnglishFrenchFax*Email* Website* Exhibitor / Sponsorship OpportunitiesExhibitor Opportunities Government / For Profit Not For Profit Not for Profit - Both Conferences (International Public Health and Palliative Care Conference and the Canadian Hospice Palliative Care Conference) Number of Booths*123456The CHPCA reserves the right to assign exhibit space at its own discretion.Number of Booths*123456The CHPCA reserves the right to assign exhibit space at its own discretion.Number of Booths*123456The CHPCA reserves the right to assign exhibit space at its own discretion.Sponsorship Opportunities Partner Level Sponsor (6 opportunities) Compassion Level Sponsor (6 opportunities) Dignity Level Sponsor (unlimited opportunities) *Cost of equipment and connection may be at an additional cost.Option Yes, I would like to exhibit at both the IPHPC and CHPC conferences Partner Level – Satellite Symposium Sponsor (2 opportunities) Partner Level Sponsors have the opportunity to exhibit at both the International Public Health and Palliative Care Conference and the Canadian Hospice Palliative Care Conference for $10,000 extra. Partner Level Sponsors also have the opportunity to to host one of two sponsored symposiums* during the conference. These sponsored sessions will be offered at the following times: Monday, September 18 - Lunch**: 11:50 am - 1:15 pm Tuesday, September 19 - Lunch**: 11:50 am - 1:15 pm *Working directly with the IPHPC Conference Program Committee, topics and speakers must be approved prior to acceptance. **Plus catering costs.Advertising Opportunities – Conference Syllabus Full page (B&W) Full page (colour) Half page (B&W) Half page (colour) Quarter page (B&W) Quarter page (colour) Business card size (B&W) Business card size (colour) Insert in Coference Tote Bag $1,000 Yes Payment Details To receive early bird exhibitor rates, completed application for and full payment must be received by the CHPCA on or before April 30, 2017Total $ 0.00 CAD Method of Payment*Credit CardChequeMoney OrderPlease make cheque / money order payable to: Canadian Hospice Palliative Care Association > Send to: Canadian Hospice Palliative Care Association C/O Kelly MacLaren 60 Cambridge St. North Saint Vincent Hospital - Annex D Ottawa, ON K1R 7A5 CanadaI Agree To Terms and Conditions* Yes I acknowledge and agree to the 2017 Conference Exhibitor Terms and Conditions. Please click here to view the Terms and Conditions. Please click here to download the terms and conditions: Conference Exhibitor Terms and ConditionsSponsorship/Exhibitor Registration Cancellation Policy In the event that you must cancel your sponsorship/exhibitor registration, the Canadian Hospice Palliative Care Association must receive written notice of cancellation by fax or email. Requests should be submitted to: Kelly MacLaren Development & Partnership Officer Canadian Hospice Palliative Care Association Annex D, Saint Vincent Hospital 60 Cambridge Street, Ottawa, ON K1R 7A5 1-800-668-2785 ext 224 613-241-3663 ext 224 firstname.lastname@example.org www.chpca.net Cancellation Requests Received: • On or before May 7th, 2017 75% refund • May 8th, 2017 to August 2nd, 2017 50% refund • On or after August 3, 2017, No refund If your sponsorship/exhibitor registration fee was paid by credit card within 30 days of cancellation the credit card will be refunded. If your sponsorship/exhibitor registration paid was paid by cheque or money order, or after 30 days of payment you will receive a refund cheque in the mail.I Agree to the Cancellation Policy* Yes I have read and understand the Canadian Hospice Palliative Care Conference Sponsorship/Exhibitor Registration Cancellation Policy.Product Name Price: $ 0.00 CAD Quantity: This iframe contains the logic required to handle AJAX powered Gravity Forms.