AAWC/A4M Exhibit.qxd - Worldhealth.net
AAWC/A4M Exhibit.qxd - Worldhealth.net
AAWC/A4M Exhibit.qxd - Worldhealth.net
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Anti-Aging World Conference 2004 - Paris, France - March 19-21, 2004<br />
SPACE APPLICATION FORM - Part 1<br />
To be returned before December 15, 2003 to: <strong>A4M</strong><br />
1510 West Montana Street - CHICAGO, IL 60614 - USA<br />
Phone: (773) 528-4333 - Fax: (773) 528-5390<br />
Company Name<br />
Contact<br />
Address<br />
Zip code<br />
Country<br />
Phone<br />
E-mail<br />
❏ Medical products or services relating to<br />
the practice of dermatology, surgery,<br />
aesthetic medicine and anti-aging medicine<br />
❏ Pharmaceuticals<br />
❏ Equipment and devices designed for<br />
dermatologic or biological diagnosis<br />
❏ Cosmetics<br />
City<br />
Fax<br />
Categories of Products / Services<br />
❏ Dermatology<br />
❏ Anti-aging medicine treatments<br />
❏ Nutrition, Dietetics and health food<br />
❏ Scientific/medical educational publications<br />
❏ Professional and educational organizations<br />
❏ Products/services relating to the support<br />
of non-medical aspects of the practice of<br />
dermatology, surgery and anti-aging<br />
medicine (office equipment, record<br />
keeping equipment or services, etc)<br />
❏ Others (precise): ........................................................................................................................................<br />
........................................................................................................................................................................<br />
Please tick your choice(s):<br />
❏ GOLD SPONSORING (see details page 6)..........................................................20,400 $<br />
(you will be shortly contacted)<br />
❏ STAND RESERVATION (see details page 6) - If you participate for the 1 st time, please join a list of exhibited products<br />
❏ Linear booth - 6 m 2 .......................................................... 3,360 $<br />
❏ Linear booth - 9 m 2 .......................................................... 4,260 $<br />
❏ Linear booth - 12 m 2 (could be 2 x 6 m 2 booth)...... 5,160 $<br />
❏ Corner booth - 6 m 2 ...................................................... 3,960 $<br />
❏ Corner booth - 9 m 2 ...................................................... 4,860 $<br />
SELECT YOUR PREFERED LOCATION<br />
❏ Corner booth - 12 m 2 .................................................... 5,760 $<br />
❏ Corner booth - 15 m 2 .................................................... 6,660 $<br />
❏ Peninsula booth - 12 m 2 (could be 2 x 6 m 2 booth) .... 6,480 $<br />
❏ Peninsula booth - 18 m 2 .................................................. 8,280 $<br />
❏ Additional m 2 : Linear: 360 $ x .................... m 2 = .............. $<br />
Corner: 384 $ x .................. m 2 = .............. $<br />
Peninsula: 420 $ x ................ m 2 = .............. $<br />
1 st Choice ............................ 2 nd Choice ............................ 3 rd Choice ........................ 4 th Choice ...................... 5 th Choice..........................<br />
Comment: ....................................................................................................................................................................................................................<br />
❏ Please provide our booth with 1 table and 2 chairs<br />
❏ ADDITIONAL EXHIBITOR BADGES (see details page 6)<br />
Access to exhibit hall only : 60 $ ...................................... : 60 $ x ...........badges = .............. $<br />
Access to conference rooms : 180 $ .............................. : 180 $ x ...........badges = .............. $<br />
STATEMENT Total 1 st part (VAT excl.) = .............................................. $<br />
If your have ordered a sponsorship on the 2 nd part Total 2 nd part (VAT excl.) = .............................................. $<br />
of this form (workshop, advertising, etc), please<br />
indicate here the total amount of your order.<br />
Total (VAT excl.) = .............................................. $<br />
Total VAT 19,6% = .............................................. $<br />
Total 1 + 2 (VAT incl.) = .............................................. $<br />
PAYMENT (please refer to the chapter ‘deposit and payment information’ page 8)<br />
I hereby pay a deposit of ................................ $ representing 30% of the total amount due (VAT included):<br />
❏ By check labelled to the American Academy of Anti-Aging Medicine (<strong>A4M</strong>)<br />
❏ By bank transfer in $ to <strong>A4M</strong> :<br />
❏ By Credit card (3% extra charge will be added): ❏ Visa International ❏ Eurocard/Mastercard ❏ American Express<br />
Card number: Signature and firm stamp :<br />
Card holder’s name : ______________________________________________<br />
Expiry date :<br />
<br />
✂<br />
Please see over 2 nd part
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