Name of Conference Date ● Time Location 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? * 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. We will be exhibiting: * Virtually $x,xxx (add fee or delete if not appliable) Exhibit Table $x,xxx (add fee or delete if not appliable) Exhibit Table and Workshop $x,xxx (add fee or delete if not appliable) Unfortunately, we will not be able to exhibit, but would like to support your program. Company / Division Logo PLEASE SUBMIT LOGO WITH TRANSPARENT BACKGROUNDFiles must be less than 2 MB.Allowed file types: gif jpg jpeg png. Company web address Company Description You may upload photos of representatives below. Representative 1 Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Representative 2 Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Product Information You may enter links to product pages here Product Material Information Document 1 Upload pdf files of information to provide attendees.Files must be less than 2 MB.Allowed file types: gif jpg jpeg png html pdf doc docx. Information Document 2 Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx ppt. Information Document 3 If you have more than 3 documents for your booth, email [email protected].Files must be less than 2 MB.Allowed file types: gif jpg jpeg png html pdf doc docx. 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 Math question * Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. 5 + 7 =
