Mayo Clinic College of Medicine – Mayo School of CME



Leveraging the Laboratory Outreach ConferenceDoubleTree by Hilton – Rochester, MinnesotaOctober 12-13, 2016Exhibitor Registration FormDISPLAY INFORMATION – 8’x10’ booth space includes pipe/drape, electricity (if requested), table (if requested) and chairs (if requested).Exhibit Fee – Early bird (Before June 1) - $1250June 2 – August 15, 2016 - $1500If you plan to exhibit, the following information must be pany Name: FORMTEXT ?????Mailing Address: FORMTEXT ?????City/State/Zip Code: FORMTEXT ?????Name of Representative in Charge of Exhibit: FORMTEXT ?????Mailing Address: FORMTEXT ?????(If different than above)Telephone: FORMTEXT ?????Fax: FORMTEXT ?????E-mail (Required): FORMTEXT ?????PLEASE NOTE THAT REPRESENTATIVES WISHING TO ATTEND ANY OF THE CONFERENCE PRESENTATIONS MUST REGISTER FOR THE CONFERENCE. DISPLAY INFORMATION – Booth space includes electricity (if requested), table(s) and chairs.Does your display require:Electricity – 110 volt power outlet? FORMCHECKBOX Yes FORMCHECKBOX NoIf so, how many? FORMTEXT ?????Table(s) FORMCHECKBOX Yes FORMCHECKBOX NoIf so, how many (1 or 2)? FORMTEXT ?????Chair(s) FORMCHECKBOX Yes FORMCHECKBOX NoIf so, how many? FORMTEXT ?????Additional special equipment or requests? FORMTEXT ?????Name(s) of Representative(s) Participating: 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Complete and return this form NO LATER THAN August 15, 2016 to:Cara SchmidtMayo Medical Laboratories Education DepartmentSuperior Drive Support Center, 1-402 / 3050 Superior Drive NWRochester, Minnesota 55901Fax: 507-284-8016 / schmidt.cara1@mayo.eduExhibitor AgreementRegarding the Terms and Conditions for a Commercial ExhibitActivity Title: Leveraging the Laboratory Outreach ConferenceLocation: DoubleTree by Hilton, Rochester, MinnesotaDates: Oct. 12-13, 2016Agreement between: ACCREDITED PROVIDER (PROVIDER): Mayo Medical LaboratoriesANDCommercial Company (EXHIBITOR): FORMTEXT ?????Address: FORMTEXT ?????Telephone FORMTEXT ????? Fax FORMTEXT ????? Email FORMTEXT ?????Date FORMTEXT ?????The named EXHIBITOR wishes to exhibit at the above named activity for the amount of: $1, 250 (if signed before June 1, 2016) or $1,500 (if signed June 2, 2016 or later)TERMS AND CONDITIONSEXHIBITOR agrees to abide by ACCME Standards for Commercial Support as stated at :SCS 4.2: “Product-promotion material or product-specific advertisement of any type is prohibited in or during CME activities. The juxtaposition of editorial and advertising material on the same products or subjects must be avoided. Live (staffed exhibits, presentations) or enduring (printed or electronic advertisements) promotional activities must be kept separate from CME.” “Live, face-to-face CME, advertisements and promotional materials cannot be displayed or distributed in the educational space immediately before, during or after a CME activity. Providers cannot allow representatives of Commercial Interests to engage in sales or promotional activities while in the space or in the place of the CME activity.”EXHIBITOR may distribute promotional materials at their exhibit space only. Distribution of pharmaceuticals or other samples is prohibited.All commercial support associated with this activity will be given with the full knowledge of the PROVIDER. No additional payments, goods, services or events will be provided to the course director(s), planning committee members, faculty, joint sponsor, or any other party involved with the pletion of this agreement represents a commitment and payment is due and collectible by the ACTIVITY DATE unless otherwise agreed upon by the PROVIDER. PROVIDER reserves the right to refuse exhibit space to EXHIBITOR in the event of nonpayment or Code of Conduct violation.PROVIDER agrees to provide exhibit space and may acknowledge EXHIBITOR in activity announcements. PROVIDER reserves the right to assign exhibit space or relocate exhibits at its discretion.PROVIDER Federal Tax ID number is 41-1346366Please remit check payable to: Mayo Medical Laboratories. Please identify name of course on the check stub.AGREEDEXHIBITOR Representative: FORMTEXT ????? ____________________________(Name)(Signature)38087303746500PROVIDER Representative: Cara Schmidt __________________________(Name)(Signature)Mayo Medical Laboratories 3050 Superior Dr. NW, Rochester, MN 55901Telephone: 507-266-6277 Fax: 507-284-8016 ................
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