Exhibit Space Application ACFAS 2023 Annual Scientific Conference | February 9-12 | Los Angeles, California Official Company InformationList your company information as it should appear in the Final Program and on your booth identification sign.Company Name(Required) Website Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country TelephoneFaxContact person to receive all meeting correspondenceContact Name(Required) First Last Contact Title Designation Salutation Mr Ms Phone(Required)FaxEmail(Required) Mailing Address (if different from company) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country Booth Registration Booth Before 10/15/21 After 10/15/21 Fee if you use non-ACFAS hotel 10' x 10' Inline $2,425 $2,650 +$140 10' x 10' Corner $2,675 $2,900 +$150 10' x 20' Inline $4,850 $5,300 +$270 10' x 20' (1) Corner $5,100 $5,550 +$280 10' x 10' (2) Corners $5,350 $5,800 +$290 10' x 30' Inline $7275 $7950 +$300 Island Booths (minimum 20' x 20') $25.50/Sq ft $28/Sq ft +$570 Choose your booth space:(Required) 10’ x 10’ Inline 10’ x 10’ Corner 10’ x 20’ Inline 10’ x 20’ (1) Corner 10’ x 20’ (2) Corners 10’ x 30’ Inline Islands Booths (Island Booths are minimum 20’ x 20’) Island Booth Size Minimum size is 20’ x 20’PREMIUM SPACE: Add an additional 6% to the fees listed above. Island Booth payments not received by 11/15/2021 will be invoiced at the $28.00 rate.Will you be using a non-ACFAS hotel?(Required) Yes No How will you be planning to pay?(Required) Credit Card (There will be a 3% additional charge) Pay by Check Do you want to use a premium space?(Required) Yes (There will be a 6% additional charge) No Booth Location Preferences - Premium Booths have Sold Out!Consult the Exhibit Hall Floor Plan and indicate 6 choices in different areas of the hall. Every effort will be made to accommodate your request, but cannot be guaranteed. You will be invoiced once your booth is assigned. Payment will be due upon receipt via credit card or by check within 10 business days. 1st Choice 2nd Choice 3rd Choice 4th Choice 5th Choice 6th Choice Principal Products / Service to Be Exhibited(Required) Exhibitors You Prefer Not to Be Near(Required) Audio in Booth Yes No Company DescriptionSubmit your company description – 30-word limit—subject to final editing by ACFAS staff, plus company name. ACFAS does not guarantee narratives will be listed if received after December 10, 2021.Company DescriptionExhibitor Appointed ContractorExhibitors planning to use an independent contractor must complete the Request for Exhibitor Appointed Contractor form found in your online service manual (T3expo.com). The contractor must submit an EAC Form and Certificate of Insurance no later than January 24, 2022.Sponsorship OpportunitiesSponsorship give you the unique opportunity to get your brand in front of physicians throughout the scientific conference. There are numerous ways to creatively engage with attendees at the ACFAS 2022. To start the conversation, contact Dan McNeill at Dan.McNeill@ACFAS.orgAUTHORIZATION—Void without signatureI am an authorized representative of the company with full power to sign and deliver this application. The company listed agrees to comply with all instructions, rules and regulations and agrees to promptly submit all information required by the ACFAS.Authorized Officer Name First Last Authorized Officer Title PhoneThis field is for validation purposes and should be left unchanged. Join ACFAS23 Stand out even more with attendees by sponsoring one of the many opportunities available in 2023. Download the Prospectus