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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Telephone*Language Preference*EnglishFrenchFax*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.Number of Booths*123456The CHPCA reserves the right to assign exhibit space at its own discretion.Sponsorship Opportunities Partner Level Sponsor (8 opportunities) Compassion Level Sponsor (6 opportunities) Dignity Level Sponsor (unlimited opportunities) Comfort Level Sponsor (unlimited opportunities) Plenary Sponsor (3 opportunities) Stream Sponsor (2/stream available) *Cost of equipment and connection may be at an additional cost.Option Partner Level – Satellite Symposium Sponsor (2 opportunities) Partner Level Sponsors have the opportunity to host one of two sponsored symposium during the conference for $5,000 extra (each).Advertising Opportunities – Conference Syllabus Full page Half page Quarter page Business card size Insert in Coference Tote Bag $2,000 Yes Payment Details To receive early bird exhibitor rates, completed application for and full payment must be received by the CHPCA on or before April 15, 2019Total $ 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 Terms and Conditions* Yes I acknowledge and agree to the 2019 Conference Exhibitor Terms and Conditions. Please click here to download the terms and conditions: Conference Exhibitor Terms and ConditionsSponsorship/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: Brianna Hammond Project & Events Canadian Hospice Palliative Care Association Annex D, Saint Vincent Hospital 60 Cambridge Street, Ottawa, ON K1R 7A5 1-800-668-2785 ext 235 613-241-3663 ext 235 email@example.com www.chpca.net Cancellation Requests Received: • On or before March 5th, 2019 75% refund • March 6th, 2018 to May 24th, 2019 50% refund • On or after May 25th, 2019, 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.I Agree to the Cancellation Policy* Yes I have read and understand the Canadian Hospice Palliative Care Conference Sponsorship/Exhibitor Registration Cancellation Policy.EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.