Exhibit at a T1S10 Free Clinic Day Teach1:Serve10 Free Clinic Day Exhibitor Application PLEASE FILL THIS FORM OUT TO BE CONSIDERED FOR EXHIBITING AT THE TEACH1:SERVE10 FREE CLINIC DAY SERIES. ALL APPLICANTS, SPONSORS, EXHIBITORS, PRODUCTS AND PROGRAMS ARE SUBJECT TO APPROVAL BY THE COMPASSION CENTER, REGARDLESS OF PAYMENT STATUS. ALL SALES ARE FINAL. IF YOU HAVE ANY QUESTIONS REGARDING ELIGIBILITY, PLEASE CONTACT: ADMIN@COMPASSION-CENTER.ORG . IF YOU HAVE ANY QUESTIONS REGARDING THE COMPLETION OF THIS FORM, CALL 1-888-587-6720 AND ENTER EXTENSION 744, AND SOMEONE WILL ASSIST YOU. THANK YOU FOR BEING PART OF THE TEACH1:SERVE10 FREE CLINIC DAY SERIES.Select The Upcoming Event(s) You Are Interested in Reserving or Applying For: (Click All That Apply)(Required) IPAC2023GA - Teach1Serve10 Free-Clinic Day (February 22 '23 - Atlanta) Teach1Serve10 Free-Clinic Day - Clinical Practicum Workshop (May '23 - Las Vegas) IPAC2023NV - Teach1Serve10 Free-Clinic Day (October '23 - Las Vegas) Name(Required) First Last Title(Required)Company Name(Required)Website(Required) Company Overview/Description (100 Words)(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Company Phone Number(Required)Cell Phone/Text Number (You Must Authorize Text Messages)(Required)Upload Company Logo(Required)Max. file size: 12 GB. Upload Company/Product Brochure(Required)Max. file size: 12 GB. Select Booth Type HereChoose Option BelowTeach1:Serve10 BoothTeach1:Serve10 Nonprofit BoothAvailable Options and Add-OnsChoose Option BelowAdd A Booth at IPACAdd A Nonprofit Booth at IPACTotal Credit CardCard Details Cardholder Name PLEASE FILL THIS FORM OUT TO BE CONSIDERED FOR SPONSORSHIP, EXHIBITING AND/OR PARTICIPATING IN THE IPAC CONFERENCE SERIES. DUE TO A VARIETY OF REASONS, INCLUDING ACCREDITATION, NOT ALL APPLICANTS QUALIFY TO PARTICIPATE. ALL APPLICANTS, SPONSORS, EXHIBITORS, PRODUCTS AND PROGRAMS ARE SUBJECT TO APPROVAL BY THE IPA EDUCATION COMMITTEE AND/OR THE UNIVERSITY OF NEVADA, RENO SCHOOL OF MEDICINE, OFFICE OF CONTINUING MEDICAL EDUCATION, PRIOR TO ACCEPTANCE OF SPONSORSHIP, REGARDLESS OF PAYMENT STATUS. ALL SALES ARE FINAL, REGARDLESS OF ACCEPTANCE. IF YOU HAVE ANY QUESTIONS REGARDING ELIGIBILITY, PLEASE CONTACT THE IPA EDUCATION COMMITTEE AT: EDUCATION@IPA.EDUCATIONCAPTCHA Exhibit at a Teach1Serve10 Free Clinic Day Exhibit at a T1S10 Teach1:Serve10 Free Clinic Day Exhibitor Application PLEASE FILL THIS FORM OUT TO BE CONSIDERED FOR EXHIBITING AT THE TEACH1:SERVE10 FREE CLINIC DAY SERIES. ALL APPLICANTS, SPONSORS, EXHIBITORS, PRODUCTS AND PROGRAMS ARE SUBJECT TO APPROVAL BY THE COMPASSION CENTER, REGARDLESS OF PAYMENT STATUS. ALL SALES ARE FINAL. IF YOU HAVE ANY QUESTIONS REGARDING ELIGIBILITY, PLEASE CONTACT: ADMIN@COMPASSION-CENTER.ORG . IF YOU HAVE ANY QUESTIONS REGARDING THE COMPLETION OF THIS FORM, CALL 1-888-587-6720 AND ENTER EXTENSION 744, AND SOMEONE WILL ASSIST YOU. THANK YOU FOR BEING PART OF THE TEACH1:SERVE10 FREE CLINIC DAY SERIES.Select The Upcoming Event(s) You Are Interested in Reserving or Applying For: (Click All That Apply)(Required) IPAC2023GA – Teach1Serve10 Free-Clinic Day (February 22 ’23 – Atlanta) Teach1Serve10 Free-Clinic Day – Clinical Practicum Workshop (May ’23 – Las Vegas) IPAC2023NV – Teach1Serve10 Free-Clinic Day (October ’23 – Las Vegas) Name(Required) First Last Title(Required)Company Name(Required)Website(Required) Company Overview/Description (100 Words)(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Company Phone Number(Required)Cell Phone/Text Number (You Must Authorize Text Messages)(Required)Upload Company Logo(Required)Max. file size: 12 GB. Upload Company/Product Brochure(Required)Max. file size: 12 GB. Select Booth Type HereChoose Option BelowTeach1:Serve10 BoothTeach1:Serve10 Nonprofit BoothAvailable Options and Add-OnsChoose Option BelowAdd A Booth at IPACAdd A Nonprofit Booth at IPACTotal Credit CardCard Details Cardholder Name PLEASE FILL THIS FORM OUT TO BE CONSIDERED FOR SPONSORSHIP, EXHIBITING AND/OR PARTICIPATING IN THE IPAC CONFERENCE SERIES. DUE TO A VARIETY OF REASONS, INCLUDING ACCREDITATION, NOT ALL APPLICANTS QUALIFY TO PARTICIPATE. ALL APPLICANTS, SPONSORS, EXHIBITORS, PRODUCTS AND PROGRAMS ARE SUBJECT TO APPROVAL BY THE IPA EDUCATION COMMITTEE AND/OR THE UNIVERSITY OF NEVADA, RENO SCHOOL OF MEDICINE, OFFICE OF CONTINUING MEDICAL EDUCATION, PRIOR TO ACCEPTANCE OF SPONSORSHIP, REGARDLESS OF PAYMENT STATUS. ALL SALES ARE FINAL, REGARDLESS OF ACCEPTANCE. IF YOU HAVE ANY QUESTIONS REGARDING ELIGIBILITY, PLEASE CONTACT THE IPA EDUCATION COMMITTEE AT: EDUCATION@IPA.EDUCATIONCAPTCHA
