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*Fax*Email* Website* Exhibitor / Sponsorship OpportunitiesExhibitor Opportunities Government / For Profit Not For Profit Number of Booths*123456The CHPCA reserves the right to assign exhibit space at its own discretion.Sponsorship Opportunities Partner Level Sponsor Compassion Level Sponsor Grace Level Sponsor Comfort Level Sponsor Reception Sponsor Refreshment Break Sponsor *Cost of equipment and connection may be at an additional cost.Option 1 Partner Level - I would like to sponsor one of the Learning Streams. Partner Level Sponsors have the opportunity to sponsor one of the 6 Learning Streams for an additional $15,000 investment.Please choose the Stream you would like to sponsor: Stream 1: Becoming Exceptional Leaders Stream 2: ACP in Canada: Ways to Engage in this Movement: A Practical Experience Stream 3: Grief and Bereavement in a Canada Forum: The First Time Look at this Important Issue Stream 4: Clinical Practice: Pain and Symptom Management Stream 5: Clinical Practice Stream 6: Integration of a Palliative Approach: A Look at Serious Illness Option 2 Partner Level - I would like to sponsor one of the Satellite Sessions. Partner Level Sponsors have the opportunity to sponsor one of the Satelllite Sessions for an additional $10,000 investment.Please choose the Satellite Session you would like to sponsor: June 15th Lunch Session 12:30 - 2:00 p.m. June 15th or 16th Breakfast Session 7:30 - 8:30 a.m. Advertising Opportunities – Conference Syllabus Inside back page (full colour, full page) Full page (B&W) Full page (colour) Half page (B&W) Half page (colour) Quarter page (B&W) Business card size (B&W) Insert in Conference Tote Bag $1,000 Yes Payment Details To receive early bird exhibitor rates, completed application and full payment must be received by the CHPCA on or before February 28, 2018Total $ 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 the Terms and Conditions* Yes I acknowledge and agree to the 2018 Learning Institute Exhibitor Terms and Conditions. Please click here to download the terms and conditions: http://conference.chpca.net/wp-content/uploads/2018/03/The-Canadian-Hospice-Palliative-Care-Learning-Institute-Terms-and-Conditions-2018.pdf I Agree to the Cancellation Policy* Yes I have read and understand the Learning Institute Sponsorship/Exhibitor Registration Cancellation Policy.Sponsorship/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 February 28, 2018: 75% Refund, less a $75 administration fee • February 28, 2018 to May 2, 2018: 50% Refund, less a $75 administration fee • After May 2, 2018: 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. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.