High Risk Pregnancy & Heart Disease Conference Exhibitor Form

BECOME A VIRTUAL EXHIBITOR

Company Name*

Representative Name 1

Representative Email 1

Representative Phone 1

Representative Name 2

Representative Email 2

Representative Phone 2

Representative Name 3

Representative Email 3

Representative Phone 3

Attendee Name 1

Attendee Email 1

Attendee Phone 1

Attendee Name 2

Attendee Email 2

Attendee Phone 2

Attendee Name 3

Attendee Email 3

Attendee Phone 3

Products, Supplies, Equipment*

As an authorized representative of the company listed above, I understand that:

Reasonable security measures will be taken for virtual exhibits, but UT Health San Antonio accepts no responsibility for any exhibit contents, instruments, or equipment.
Exhibitors may not assign, sublet or apportion a virtual space allotted, or exhibit any goods other than those manufactured or handled by the exhibitor in the regular course of their business.
Exhibit payment does not support education and is only for the use of the exhibit space.

Representative Name*

By typing my name above, I am electronically signing this form.

Date/Time

Name of Authorized Representative

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Email

Business Telephone

Business Fax

Sponsorship Level

Payment Type

Check

Make checks payable to: UTHSCSA CME

7703 Floyd Curl Drive, Mail Code 7980, San Antonio, TX78229-3900 Federal Tax ID# 74-1586031

Credit Card

We will contact you for credit card information.