Exhibitor Application Form Exhibitor InformationPlease indicate company information exactly as it should appear in all official publications.Company Name*Mailing Address* Street Address 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 Company Phone*Company Email* Website Contact InformationPre-Show Contact Name* First Last Pre-Show Contact's TitlePre-Show Contact Phone*Pre-Show Contact Email* Is your onsite contact the same as your pre-show contact?YesNoOnsite Contact Name* First Last Onsite Contact's Title*Phone*Email* Exhibit ReservationPayment ScheduleDeposit of 50% is due upon receipt of application. Balance is due by February 22, 2019. Total booth price due with applications submitted after February 22, 2019. Pay in fullPay deposit (one-half total booth cost)Booth Price:* Price: $1,500.00 Quantity: Included in your exhibit fee are one (1) 6’ draped table, two (2) side chairs, one (1) wastebasket and (1) one-line identification sign (company name and booth number). Additional items may be purchased in your exhibitor kit that will be sent to you. Booth Price:* Price: $1,000.00 Quantity: Included in your exhibit fee are one (1) 6’ draped table, two (2) side chairs, one (1) wastebasket and (1) one-line identification sign (company name and booth number). Additional items may be purchased in your exhibitor kit that will be sent to you. Total $0.00 We prefer not to be in proximity to the following companies (please list no more than two): Booths will be assigned at the sole discretion of show management and will be based on the date that the Application is received and consideration of competition. Floor plan will be provided. No specific booth guarantees will be made until payment is received.Payment Method*I will pay by credit cardI will pay by checkPlease make check payable to the International Pediatric Endosurgery Group and send to: International Pediatric Endosurgery Group 11300 W. Olympic Blvd. Suite 600 Los Angeles, CA 90064 For more information, please contact Paula Kupiec at tel: 310-424-3326, ext. 161 or email: firstname.lastname@example.org Credit Card* American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Exhibitor Agreement* I agree to the statement below. I understand and agree to comply with all the policies, rules, regulations, terms, and conditions contained in the IPEG 2019 Exhibitor Prospectus and have read the rules and agree to distribute them to those involved with your exhibit.