28TH ANNUAL STEAMBOAT PERINATAL CONFERENCE
January 17-19, 2013
The Steamboat Grand Resort Hotel, Steamboat Springs, CO
EXHIBITOR AND SPONSOR APPLICATION
If you have any questions, please contact jaime_mejias@pediatrix.com.
Submit this application:
By Fax:
954-838-4521
By Mail:
28th Annual Perinatal Conference
c/o Jaime Mejias
1301 Concord Terrace
Sunrise, FL 33323
1. CONTACT INFORMATION:
ORGANIZATION:
PRIMARY EXHIBITOR CONTACT:
MAILING ADDRESS:
CITY:
STATE:
PHONE:
CELL:
FAX:
EMAIL:
2. WOULD YOU LIKE TO BE AN EXHIBITOR?
No
ZIP:
Yes ($1,500 exhibit fee applies)
Each exhibit space includes an 8’ tabletop and 2 chairs. Please note, exhibitors will not be allowed in the CME
classrooms.
3. WOULD YOU LIKE TO SPONSOR AN EVENT? (CHECK ITEMS OF INTEREIST AND SPECIFY
AMOUNT):
No
Yes $
(Amount)
Wednesday, January 16, 2013:
Reception
Thursday, January 17, 2013:
Breakfast
Reception
Dinner
Please initial here
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4. WOULD YOU LIKE TO PROVIDE A MEDICAL EDUCATION GRANT?
No
Yes
The MEDNAX Center for Research, Education and Quality adheres to ACCME and ANCC guidelines for commercial
support that ensure medical education is kept distinct and unbiased from commercial influence. If your company is
interested in providing a medical education request, we will provide a separate medical education grant contract.
5. PLEASE EMAIL A HIGH-RESOLUTION COMPANY LOGO (.JPG OR EPS VECTOR) TO
jaime_mejias@pediatrix.com
6. PLEASE REGISTER YOUR EXHITORS (MAXIMUM OF 3):
Name for Badge
Title
Email
Mobile Phone
Please initial here
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7. BY SIGNING BELOW, I ATTEST TO THE FOLLOWING:

I am authorized by my organization to commit funds and hereby commit funds as described above and agree to the
terms described herein.

I understand that this application, including all exhibit space and sponsorship requests, are subject to approval by the
Planning Committee, which reserves the right to, at its sole and absolute discretion, accept, reject, or limit the exhibit or
sponsorship opportunities requested by an organization.

I understand that this application will not be processed unless accompanied by full payment. Once my application and
payment have been received, I will receive a confirmation with additional information.

I understand that all exhibitors must be registered (using section 6 above) by January 7, 2013. My booth space includes
3 complimentary registrations. Amendments to the above list must be made in writing. Additions after January 7,
2013, will result in a $300 per person fee (including any onsite registrations and even if organization has not fulfilled
complimentary allotment). Amendments to registrations after January 9, 2013, will be subject to a $100 per person fee.

I understand that housing is not included with this registration form. If you wish to reserve a hotel room, please contact
Dino Garland, Heller Travel –CALL at 562.426.1768 or outside Southern California 800.426.1769, or
e-mail
dino@hellertravel.com.

The exhibitor assumes all responsibility for any and all loss, theft or damage to exhibitor’s displays, equipment and
other property while on premises, and hereby waives any claim or demand it may have against Pediatrix Medical Group
or its affiliates arising from such loss, theft or damage. In addition, exhibitor agrees to defend (if requested), indemnify
and hold harmless Pediatrix Medical Group, and is respective parent, subsidiaries and other related or affiliated
companies from and against any liabilities, obligations, claims, damages, suits, costs and expenses, including, without
limitation, attorney’s fees and costs, arising from or in connection with the exhibitor’s occupancy and use of the
exhibition premises or any part thereof or any negligent act, error or omission of the exhibitor or its employees,
subcontractors or agents.

Provided my application is approved, I hereby commit to the above sponsorship of this conference in the amount of
$
and have attached payment as specified and required below.
Signature:
Title:
8. PAYMENT
Checks:
Payable to “The MEDNAX Center for Research, Education and Quality” (Federal ID #65-0271219) and
indicate that payment is for “28th Annual Perinatal Conference”. All payments must be in U.S. dollars drawn
on a U.S. bank.
Charge:
MasterCard
Charge total amount due $
VISA
American Express
Cardholder’s Name:
Card Account Number:
Billing Street
CID Number (located on back of card):
City
State:
Zip:
Expiration Date:
Cardholder’s Signature:
Please initial here
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