American College of Nurse - Midwives (ACNM) September 20 & 21, 2024 ● 8:30 am - 5:00 pm Baystate Health Education Center361 Whitney Ave. Holyoke, MA 01040 Standards for Integrity and Independence in Accredited Continuing EducationBaystate Health Continuing Interprofessional Education follows the ACCME Standards for Integrity and Independence in Accredited Continuing Education. AgreementBy completing this form you agree to abide by these standards. • When commercial exhibits are part of the overall program, arrangements for these will not influence planning or interfere with the presentation of continuing education activities. • Exhibit placement is not a condition of support for a continuing education activity. • No commercial promotional materials shall be displayed or distributed in the same room immediately before, during, or immediately after an educational activity certified for credit. • Representatives of commercial supporters may attend an educational activity, but may not engage in sales activities while in the room where the activity takes place. Company Name * Representative Name(s), telephone number, email * Payment will be made via * Charge Card (preferred) Check ACH Contact Marion Talbot (413-794-9783) to process charge card payment. Make check payable to: Baystate Continuing Interprofessional Education Mail to: Baystate Health, 3601 Main St., Springfield, MA 01199-0001 TAX ID #04-2105941 Notify [email protected] when payment has been processed. Is payment processed through a third party? * Will payment be coming from a company other than yours? If yes, please enter company name. Yes No Company name (and contact info if available) from third party payer: Please DO NOT enter payment information here. Refer to exhibit request packet. Exhibitor package:One 6-foot table, 2 complimentary attendee registrations (in-person or on-line attendance), company sponsor acknowledgment in handout materials, optional company handout/materials in conference bag. Gold package(Sponsorship of specific educational session or meal) Sponsorship announced to audience, 2 complimentary attendee registrations (on-line attendance only), company sponsor acknowledgment in handout materials, and optional company handout/materials in conference bag. Silver package:Advertising display in exhibitor space (e.g. poster, banner, and/or easel, to be provide by sponsor), 2 complimentary attendee registrations (on-line attendance only), company sponsor acknowledgment in handout materials, and optional company handout/materials in conference bag. Bronze package:Company sponsor acknowledgment in handout materials, and optional company handout/materials in conference bag. Select sponsorship level * Exhibitor package $1,200 Gold package $1,000 Silver package $500 Bronze package $250 By completing and submitting this form, I agree to abide by the policy above and to pay the selected exhibit/display fee. Leave this field blank