acns fall courses · a a orss ehibit & support prospectus september 28-29, 2013 •...

ACNS Fall Courses Exhibit & Support proSpEctuSSeptember 28-29, 2013 • philadelphia, penn.

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Exhibit & Su

pport pro

SpEctu

S

September 28-29, 2013 • philadelphia, penn.

doubletree by hilton • philadelphia Center City

www.acns.org

ACNS Fall Courses

ameriCan CliniCal neurophySiology SoCiety555 East Wells Street, Suite 1100Milwaukee, WI 53202Phone: 414-918-9803Fax: [email protected]


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about aCnS

about the ameriCan CliniCal neurophySiology SoCiety (aCnS)

ACNS is a professional association dedicated to fostering excellence in clinical neurophysiology and furthering the understanding of central and peripheral nervous system function in health and disease through education, research, and the provision of a forum for discussion and interaction.

Founded in 1946 and originally named the American Electroencephalographic Society (AEEGS), ACNS is the major professional organization in the United States devoted to the establishment and maintenance of standards of professional excellence in clinical neurophysiology in the practice of neurology, neurosurgery and psychiatry. ACNS members utilize neurophysiology techniques in the diagnosis and management of patients with disorders of the nervous system and in research examining the function of the nervous system in health and disease.

aCnS eduCational miSSion Statement

ContentACNS is committed to providing continuing medical education to its members and others interested in clinical neurophysiology. Educational objectives include 1) Reviewing current knowledge of clinical neurophysiology including: electroencephalography, evoked potentials, electromyography, nerve conduction studies, intraoperative monitoring, polysomnography and other sleep technology, quantitative neurophysiological methods, magnetoencephalog-raphy, sleep disorders, epilepsy, neuromuscular disorders, brain stimulation, brain-computer interfacing, and related areas; and 2) Informing course and meeting attendees of recent tech-nological developments and their implications for clinical practice.

target audienCeThe Society’s educational activities are directed to clinical neurophysiologists, neurologists, psychiatrists, physiatrists, neurosurgeons, trainees in these disciplines and other physicians and researchers who utilize clinical neurophysiological techniques and knowledge in the diagnosis and management of patients with disorders of the nervous system.

expeCted reSultAttendees will improve competence in clinical neurophysiology procedures and incorporate new technological advancements into their practice.

table of ContentS

About ACNS ......................................2

ACNS Council .................................. 2

About the Fall Courses .................... 3

Important Dates ................................ 3

Philadelphia Visitor Information ....................................... 3

Preliminary Program ....................... 4

General Exhibitor Information ....... 8

Support Opportunities ...................10

Exhibit Application & Contract ..........................................11

Support Application & Contract ..........................................13

aCnS CounCil

preSidentFrank W. Drislane, MDBeth Israel Deaconess Medical Center

firSt ViCe preSidentAatif M. Husain, MDDuke University Medical Center

SeCond ViCe preSidentWilliam O. Tatum, DOMayo College of Medicine

SeCretary Jonathan C. Edwards, MDMedical University of South Carolina

treaSurerStephan U. Schuele, MD, MPHNorthwestern University

immediate paSt preSidentSusan T. Herman, MDBeth Israel Deaconess Medical Center

paSt preSident Douglas R. Nordli, Jr., MDChildren’s Epilepsy Center

CounCilorS-at-largeSelim R. Benbadis, MDUniversity of South Florida

Jeffrey Britton, MDMayo Clinic

Cecil D. Hahn, MD, MPHThe Hospital for Sick Children

Tobias Loddenkemper, MDChildren’s Hospital Boston

Jaime Lopez, MDStanford University

Suraj Muley, MDBarrow Neurological InstituteSt. Joseph’s Hospital & Medical Center

Raj D. Sheth, MDMayo Clinic/Nemours Clinic-Florida

Francis O. Walker, MDWake Forest University

ama offiCerMarc R. Nuwer, MD, PhDUCLA

Journal editorJohn Ebersole, MDUniversity of Chicago Medical Center


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about the fall CourSeS

about the fall CourSeS

The 2013 Fall Courses are designed around two of the new and rapidly-evolving areas of clinical neurophysiology: Neurological Intraoperative Monitoring (NIOM) and Intensive Care Unit EEG Monitoring (ICU EEG). Few practicing neurologists have adequate training in these techniques, and physicians with competence in these are in great demand. Educational activities will cover both basic methodologies for those practitioners new to ICU EEG and NIOM as well as innovative techniques.

meeting Venue

DoubleTree by Hilton Philadelphia Center City237 S Broad Street Philadelphia, PA 19107(215) 893-1600

target audienCe

Clinical neurophysiologists, neurologists, physiatrists, neurosurgeons, technologists, trainees in these disciplines and other physicians and researchers who specialize in clinical neurophysiology.

obJeCtiVeS

ICU EEG Course Objectives1. At the conclusion of this course, participants will be able to: 2. Recognize common indications for CEEG in the ICU setting;3. Interpret EEG patterns encountered in the ICU, including

seizures and periodic patterns;4. Utilize quantitative EEG methods for data reduction and real-

time detection of EEG changes in the ICU;5. Select appropriate equipment for ICU-EEG monitoring,

including networking and data storage options, and;6. Determine optimal staffing, data review, and reporting of

results.

niom CourSe obJeCtiVeS

At the conclusion of this course, participants will be able to: 1. Identify the various types of NIOM;2. Recognize common indications for performing various types

of NIOM;3. Identify changes that can occur during NIOM; 4. Differentiate between typical and atypical changes that occur

during NIOM;5. Illustrate the technical challenges associated with NIOM;6. Describe contemporary issues relevant to NIOM;7. Differentiate between legal, practice, and equipment issues

relevant to NIOM

paSt attendanCe

2012 exhibitorS

American Board of Clinical Neurophysiology (ABCN)American Board of Registration of Electroencephalographic and

Evoked Potential Technologists (ABRET)ASET – The Neurodiagnostic SocietyCadwell LaboratoriesElectrical GeodesicsGrass TechnologiesIdeal Health Careers, Inc.Moberg Research/CNS TechnologyNatus MedicalNihon KohdenPMT CorporationRhythmlink InternationalUCB, Inc.

important dateS

Exhibitor Booth Application Opens June 20, 2013Exhibitor Staff Registration Opens June 20, 2013Exhibitor Booth Application Deadline August 27, 2013Exhibitor Staff Registration Deadline August 27, 2013Exhibitor Space Cancellation Deadline August 30, 2013

philadelphia ViSitor information

Philadelphia, known as the “City of Brotherly Love,” is rich in American history. It is home to some of the most significant monuments in American history, including Independence Hall and the Liberty Bell.

The DoubleTree by Hilton Philadelphia Center City is located only minutes from these historic monuments. Also nearby, the Rittenhouse Row area is home to Philadelphia’s most-loved outdoor sculptures, art galleries, haute couture boutiques, national retailers, specialty shops, luxurious spas and salons, restaurants and cafés. Some of Philadelphia’s most popular restaurants are located on Rittenhouse Row, including Rouge, Devon, Parc and Barclay Prime.

For more information on Philadelphia and directions to the Fall Courses, please visit www.acns.org/meetings/fall-courses/2013/travel-information.

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http://www.acns.org/meetings/fall-courses/2013/travel-information

http://www.acns.org/meetings/fall-courses/2013/travel-information

Preliminary Program – subject to change


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The two courses, “ICU EEG” and “Neurological Intraoperative Monitoring (NIOM),” run concurrently on both Saturday, September 28 and Sunday, September 29. Each course will be located in a room adjacent to the registration and exhibits area.

iCu eeg

Course Co-Directors: Nicholas S. Abend, MD & Saurabh Sinha, MD, PhD

Saturday, September 28

8:00 – 8:10am Welcome and Introduction Nicholas S. Abend, MD

8:10 – 10:00am Seizures – Indications and Outcome Neonatal Courtney J. Wusthoff, MD Pediatric Nicholas S. Abend, MD Adult Saurabh Sinha, MD, PhD

10:00 – 10:30am Break & Visit Exhibits

10:30am – 12:00pm Other Indications Ischemia Identification Susan T. Herman, MD Prognosis – Neonatal and Pediatric William Gallentine, DO Prognosis – Adult Susan T. Herman, MD

12:00 – 1:00pm Lunch & Visit Exhibits

1:00 – 3:30pm EEG Interpretation Background – Neonatal and Pediatric Courtney J. Wusthoff, MD Background – Adult Saurabh Sinha, MD, PhD Electrographic Seizures Suzette M. LaRoche, MD Periodic and Rhythmic Patterns Elizabeth E. Gerard, MD

3:00 – 3:30pm Break & Visit Exhibits

3:30 – 5:00pm Quantitative EEG Intro and Utility Cecil D. Hahn, MD, MPH Cases – Seizures Cecil D. Hahn, MD, MPH; Susan T. Herman, MD; Courtney J. Wusthoff, MD Cases – Ischemia Susan T. Herman, MD

5:00 – 6:30pm Reception & Visit Exhibits



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iCu eeg

Sunday, September 29

7:30 - 8:45am Hands on Quantitative EEG Workshop Susan T. Herman, MD

9:00 – 10:45am Administrative Issues Equipment, Networking, Electrodes, Montages Saurabh Sinha, MD, PhD Staffing/Personnel, Team Approach2 Cecil D. Hahn, MD, MPH Billing, Coding, and Epilepsy Center Guidelines Stephen Hantus, MD

10:45 – 11:00am Break

11:00am – 12:00pm Developing a CEEG Program, Current Practices Developing a Program and Business Plan Stephen Hantus, MD Panel Discussion Cecil D. Hahn, MD, MPH; Stephen Hantus, MD; Susan T. Herman, MD; Saurabh Sinha, MD, PhD

12:00 – 1:00pm Lunch

1:00 – 2:15pm Seizure and Status Epilepticus Management Neonatal Courtney J. Wusthoff, MD Pediatric William Gallentine, DO Adult Elizabeth E. Gerard, MD Novel Treatments Elizabeth E. Gerard, MD

2:15 – 2:30pm Break

2:30 – 3:30pm Other Topics Multi-Modal Monitoring Suzette M. LaRoche, MD ICU EEG Guidelines Nicholas S. Abend, MD Impact on Management and Outcome Suzette M. LaRoche, MD

3:30 – 4:00pm Panel Discussion, Q&A

4:00pm Closing Remarks Saurabh Sinha, MD, PhD



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neurologiC intraoperatiVe monitoring (niom)Course Co-Directors: Aatif Husain, MD & Marc R. Nuwer, MD, PhD

Saturday, September 28

8:00 – 8:05am Introduction & Welcome Aatif M. Husain, MD

8:05 – 8:45am SEP Aatif M. Husain, MD

8:45 – 9:25am MEP Ronald Emerson, MD

9:25 – 10:05am EMG Stanley Skinner, MD

10:05 – 10:20am Break & Visit Exhibits

10:20 – 11:00am Case Discussion: Vertebral Column Surgery Ronald Emerson, MD

11:00 – 11:40am Case Discussion: Spinal Cord Surgery Eva K. Ritzl, MD

11:40am – 12:00 Question & Answer Panel: Ronald Emerson, MD; Aatif M. Husain, MD; Eva K. Ritzl, MD; Stanley Skinner, MD

12:00 – 1:00pm Lunch & Visit Exhibits

1:00 – 1:40pm BAEP and CN 7 Alan D. Legatt, MD, PhD

1:40 – 2:20pm EEG Jaime Lopez, MD

2:20 – 3:00pm Case Discussion: CPA Surgery Alan D. Legatt, MD, PhD

3:00 – 3:15pm Break & Visit Exhibits

3:15 – 3:55pm Case Discussion: Carotid Endarterctomy Eva K. Ritzl, MD

3:55 – 4:35pm Case Discussion: Intracranial Aneurysm Surgery Jaime Lopez, MD

4:25 – 5:00pm Question & Answer Panel: Alan D. Legatt, MD, PhD; Jaime Lopez, MD; Eva K. Ritzl, MD

5:00 – 6:30pm Reception & Visit Exhibits



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neurologiC intraoperatiVe monitoring (niom)

Sunday, September 29

8:00 – 8:05 Welcome Marc R. Nuwer, MD, PhD

8:05 – 8:45am Anesthesia Ronald Emerson, MD

8:45 – 9:25am Cranial Nerves 3, 4, 6 Jaime Lopez, MD

9:25 – 10:05am Cranial Nerves 5, 9-12 Alan D. Legatt, MD, PhD

10:05 – 10:20am Break

10:20 – 11:00am Case Discussion: Brainstem Surgery Jaime Lopez, MD

11:00am – 11:40am Case Discussion: Lower Spinal Surgery Stanley Skinner, MD

11:40am – 12:00pm Question & Answer Panel: Ronald Emerson, MD; Alan D. Legatt, MD, PhD; Jaime Lopez, MD; Stanley Skinner, MD

12:00 – 1:00pm Lunch & Business of NIOM

1:00 – 1:40pm Billing and Regulatory Issues Marc R. Nuwer, MD, PhD

1:40 – 2:20pm Cortical Mapping and Stimulation Marc R. Nuwer, MD, PhD

2:20 – 2:35pm Break

2:35 – 3:15pm Case Discussion: Brain Tumor Surgery Eva K. Ritzl, MD

3:15 – 3:55pm Case Discussion: Aortic Surgery Aatif Husain, MD

3:55 – 4:15pm Question & Answer Panel: Aatif Husain, MD; Marc R. Nuwer, MD, PhD; Eva K. Ritzl, MD


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general exhibitS information

Exhibits are an important part of the educational experience for Fall Courses attendees. Breakfast, lunch and coffee breaks will be served in exhibit hall, which is adjacent to both course session rooms. A reception will also be hosted for meeting delegates on Saturday evening, September 28 in the exhibit hall.

important dateS

Exhibitor Booth Registration Opens June 20, 2013Exhibitor Staff Registration Opens June 20, 2013Exhibitor Booth Application Deadline August 27, 2013Exhibitor Staff Registration Deadline August 27, 2013Exhibitor Space Cancellation Deadline August 30, 2013

exhibit feeS - $500 per table

Tabletop exhibits include:• One (1) 6’ draped & skirted table;• Complimentary registration for one (1) company personnel;• Acknowledgement in the Fall Courses final program materials

and ACNS website.• Acknowledgement in the December issue of Clinical

Neurophysiology News, the official newsletter of ACNS, distributed electronically to the 900+ ACNS members and archived to the Members-Only section of the ACNS website.

exhibit hourS (SubJeCt to Change)

Saturday, September 28 7:00 – 8:00am Exhibitor Move-In 10:00 – 10:30am Morning break 12:00 – 1:00pm Lunch 3:00 – 3:30pm Afternoon break 5:00 – 6:30pm Reception 7:00 – 8:00pm Exhibitor Move-Out

exhibit perSonnel regiStration

All exhibitor personnel must be registered. One (1) complimentary registration is provided to each exhibitor. Exhibitor registrations provide access to the exhibit hall and food and beverage functions on Saturday, September 28. Each exhibiting company is allowed additional exhibitor registrations at $600 per additional individual before August 27 or $650 per additional individual onsite. Exhibitor personnel may attend sessions, space permitting, but may not claim CME credits for attendance at the courses.

CanCellation poliCy

Requests for cancellation of exhibit space must be made in writing. Written cancellation requests received before August 30, 2013 will receive a refund, less 20% processing fee. Refunds will not be issued after August 30, 2013.

SerViCe ContraCtor

Due to the limited nature of the Fall Courses exhibition, a general service contractor will not be available. Exhibitors are responsible for shipping to and from show site, provision of labor, set-up, removal, etc.

Shipping

Exhibit materials may be shipped directly to the Doubletree as follows:

Exhibitor Company NameExhibitor Contact Namec/o ACNS Fall CoursesDoubletree by Hilton Philadelphia Center City237 S. Broad StreetPhiladelphia, PA 19107

A $4.00 per box delivery fee will be charged by the hotel directly to the exhibitor. Please see page 14 to make arrangements for payment of materials handling charges.

eleCtriCity

Electrical drops are not included in the standard exhibit fee. Companies wishing to arrange for electricity to their exhibit table may make arrangements directly with the Doubletree Philadelphia Center City. Please find an application for electricity and other exhibit needs (beyond those provided by ACNS, see above) at the back of this prospectus.

inSuranCe

Each exhibitor is responsible for maintaining insurance against injury to person or damage to or loss of property in such amounts as the exhibitor shall deem adequate. Insurance protection will not be afforded to the exhibitor by ACNS or the hotel.

liability & indemnifiCation

The exhibitor will be fully responsible for any claims, liabilities, losses, damages, or expenses, including attorney’s fees, relating to or arising out of any loss of injury to, or damage to any person or property of the exhibitor or any other property where such injury, loss or damage is incident to, arises out of or is in any way connected with the exhibitor’s participation in the exhibition. The exhibitor shall protect, indemnify, hold harmless, and defend ACNS, its officers, directors, agents or servants, and employees from and against any and all such claims, liabilities, losses, damages, and expenses, including attorneys’ fees, provided that the foregoing shall not apply to injury, loss, or damage caused by or resulting from the negligence or willful misconduct of ACNS, its officers, directors, agents, or employees.

fire & Safety regulationS

Exhibitors must comply with all federal, state, and local fire building codes that apply to the facility.


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general exhibitS information

labor regulationS

Exhibitors are required to conform to all local labor regulations.

Smoking

Smoking is prohibited at the ACNS Fall Courses.

interpretation & appliCation of ruleS & regulationS

Show management reserves the right to: (a) reject for any reason, without explanation, any exhibit application submitted for the ACNS Fall Courses; (b) reject, prohibit, restrict, or otherwise require modification of any exhibit for any reason; and (c) evict or bar any exhibitor whose exhibit, materials, or conduct is objectionable to show management for any reason. Violation of any regulations on the part of the exhibitor, its employees or agents shall void the right to occupy space, and such exhibitor will forfeit to ACNS all monies which may have been paid. Upon evidence of violation, management may re-enter and take possession of the space occupied by the exhibitor, and may remove all persons and goods at the exhibitor’s risk. The exhibitor shall pay all expenses and damages which management may incur thereby.

exhibitor appliCation information

To reserve a table, complete the application and contract for exhibit space on page 11 and return it with full payment to the ACNS Executive Office. Exhibit space is assigned based on the date the application is received.

appliCation reView

ACNS will review all exhibit applications to determine whether they satisfy basic criteria such as: whether the product/services described specifically relate to the practice of clinical neurophysiology, and whether the exhibit is of informational value to Fall Course delegates.

produCt/SerViCe deSCriptionS

Product and/or service descriptions are a required part of the application process. The description will appear under the company name in the final program under the exhibit directory. All descriptions should be in sentence format, typed and no longer than 100 words. Descriptions longer than 100 words will be edited for length. Descriptions for the final program will be accepted until August 27, 2013. Please attach description to the application or email it to [email protected].

exhibitor reloCation

If it becomes necessary to relocate an exhibitor after a space assignment has been made, ACNS will contact the company involved and every effort will be made to reassign the exhibitor to a similar space.


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Support opportunitieS

Gain increased exposure by supporting the 2013 Fall Courses. Your contribution helps support ACNS educational programs and attendee services. In addition to valuable networking opportunities, you will receive the following benefits:

gold leVel Support ($3,000+)

• Acknowledgement as outlined pertaining to specific grant opportunities chosen;

• Acknowledgement in the Fall Courses final program materials and ACNS website;

• One (1) full-page acknowledgement in the December issue of Clinical Neurophysiology News, the official newsletter of ACNS, distributed electronically to the 900+ ACNS members and archived to the Members-Only section of the ACNS website.

SilVer leVel Support ($1,000 - $2,999)


• Acknowledgement in the Fall Courses final program materials and ACNS website;

• One (1) half-page acknowledgement in the December issue of Clinical Neurophysiology News, the official newsletter of ACNS, distributed electronically to the 900+ ACNS members and archived to the Members-Only section of the ACNS website.

bronze leVel Support (up to $999)


• Acknowledgement in the Fall Courses final program materials and ACNS website.

final program adVertiSing

Advertising space is available in the 2013 Fall Courses Final Program, which is distributed to all delegates upon check-in and posted to the ACNS website in advance of the meeting. The Final Program will contain information on the scientific program, catered functions, program CME and ACNS membership.

inSide front CoVer $1,500 Your full page ad (designed at supporter’s discretion, subject to ACNS approval) will appear just inside the program’s cover, opposite the table of contents and is sure to grab delegate’s attention.

inSide baCk CoVer $1,000 Your full page ad (designed at supporter’s discretion, subject to ACNS approval) will appear at the end of the program, opposite notes pages.

Artwork specifications for front and back covers:• Dimensions: 5 ¾” x 8 ¾” (with bleeds)• Finish Size: 5 ½” x 8 ½”• Color: CMYK• File Format: High resolution (at least 300 dpi); PDF,

TIF, JPG or EPS.

noteS pageS $500 each pagePlace your logo and tagline as the header or footer on a series of blank pages at the back of the program, designed for delegates to take notes on presentations, write down contact information while networking, and to serve as a reference following the meeting.

wireleSS internet $2,500

Help Fall Courses delegates stay in touch and informed by providing prepaid wireless Internet access cards. Access to the Internet is available in all public areas of the hotel for those delegates traveling with their laptops. ACNS will distribute to delegates a card containing log-on instructions and passwords. A single supporter may brand the cards with their logo and tagline (subject to ACNS approval) and will also be acknowledged in the Final Program.

breakfaSt $1,000 per day

Reach all 120+ delegates first thing each morning as they prepare for a day of education. Continental breakfast will be served Saturday morning in the exhibit hall and Sunday morning near registration. As a supporter of one of the daily breakfasts, your company will be identified on signage as well as in Final Program materials. If possible, catering stations may be strategically placed in proximity to the supporters’ booth on Saturday.

beVerage break $500 per break

As a supporter of one of the breaks, your company will be allowed to include educational materials in the beverage break areas to draw attendees to your booth and will be acknowledged in the Final Program and on signage in the break area. Both morning and afternoon refreshment breaks will be scheduled.

boxed lunCh $2,000

Lunches will be provided for delegates on Saturday in the exhibit hall. As a supporter of the boxed lunches, your company will be identified on signage as well as in Final Program materials. If possible, catering stations may be strategically placed in proximity to the supporters’ booth.

unreStriCted eduCational grant

By providing an educational grant in any amount, your company can help off-set Fall Courses expenses, and help keep meeting registration fees low.


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exhibit appliCation & ContraCt deadline for appliCation: auguSt 27, 2013

organization /ContaCt information

Organization: _____________________________________________________________________________________________

Contact Person: ____________________________________________________________________________________________

Title: ____________________________________________________________________________________________________

Address: __________________________________________________________________________________________________

City: _______________________________ State: ________ Zip/Postal Code: ___________ Country: ______________________

Phone: _________________________________________ Fax: ____________________________________________________

E-mail (all exhibitor information will be sent to the e-mail address specified): ___________________________________________

exhibit table appliCation:

# of tables_________ x $500 = ____________________________(total due)

Complimentary exhibitor regiStration

Each company is allowed ONE complimentary registrations per table, with additional registrations charged at $600 per individual.

1. Name: _________________________________________________________________________________________________

Email: _________________________________________________________________________________________________

2. Name: _________________________________________________________________________________________________

Email: ___________________________________________________________________________________________ x $600

3. Name: _________________________________________________________________________________________________

Email: ___________________________________________________________________________________________ x $600

4. Name: _________________________________________________________________________________________________

Email: ___________________________________________________________________________________________ x $600

5. Name: _________________________________________________________________________________________________

Email: ___________________________________________________________________________________________ x $600

total $______________________exhibit direCtory information:

All information will appear in the Final Program exactly as it appears below.

Company: ________________________________________________________________________________________________

Address: __________________________________________________________________________________________________


Phone: __________________________________________ Fax: ____________________________________________________

E-mail _______________________________________ Website: ____________________________________________________

produCt /SerViCe deSCription: Submit, in 100 words or less, a description of the products, equipment, services or facility that will be exhibiting. ACNS reserves the right to edit text to conform to length limit. Description may also be emailed to: [email protected].

Please see next page for payment options.

mailto:[email protected]


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method of payment: Applications will not be processed without payment and signature.

Company Check – Make check payable to American Clinical Neurophysiology Society (in US Dollars, drawn on a US bank)

Credit Card (check one): ____VISA ____MasterCard

Amount to Charge: $____________

Card Number: ________________________________________ _______________ Expiration Date: ______________________

Card Holder Name: _________________________________________________________________________________________


Card Holder Signature __________________________________________________________ Date: ______________________

Signature of agreement: Please retain a copy for your records. You are hereby authorized to reserve space for the company/organization listed above in the exhibition of the 2013 ACNS Fall Courses, September 28-29, 2013, at the DoubleTree by Hilton Philadelphia Center City. We understand that the assigned space will be rented at the rate quoted in the prospectus. We understand further that all space must be paid in full upon completion of the application. If assigned space is not paid for in full at time application is submitted, it may be reassigned to another exhibitor at the discretion of ACNS. The exhibiting company agrees to abide by all rules and regulations governing exhibits set forth in the prospectus, which is made part of this contract by reference and fully incorporated herein.

Print Name: _______________________________________________________________________________________________

Authorized Signature: ___________________________________________________________ Date: ______________________

pleaSe return thiS appliCation with required payment to: American Clinical Neurophysiology Society

Attn:SamanthaSurillo•555E.WellsStreet,Suite1100•Milwaukee,WI53202 Phone:(414)918-9803•Fax:(414)276-3349•E-mail:[email protected]

exhibit appliCation & ContraCt — Continued


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Support appliCation & ContraCt deadline for appliCation: auguSt 27, 2013

organization /ContaCt information

Organization: ______________________________________________________________________________________________

Contact Person: _____________________________________________________________________________________________

Title: _____________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

City: _______________________________ State: ________ Zip/Postal Code: ___________ Country: _______________________

Phone: __________________________________________ Fax: _____________________________________________________

E-mail (all exhibitor information will be sent to the e-mail address specified): ____________________________________________

Final Program Advertising ☐ Inside front cover $1,500 ☐ Inside back cover $1,000 ☐ Notes pages $500 each page x ______ = $_________

☐ Wireless Internet $2,500

☐ Breakfast $1,000 per day x ______ = $_________ (circle) Saturday Sunday

☐ Beverage Break $500 per break x ______ = $_________ (circle) Saturday AM Saturday PM Sunday AM Sunday PM

☐ Boxed Lunch $2,000 x ______ = $_________ (circle) Saturday Sunday

☐ Unrestricted Educational Grant $______________________

total due $______________________

method of payment: Applications will not be processed without payment and signature

Company Check – Make check payable to American Clinical Neurophysiology Society (in US Dollars, drawn on a US bank)

Credit Card (check one): ____VISA ____MasterCard

Card Number: ________________________________________ _______________ Expiration Date: ______________________

Card Holder Name: _________________________________________________________________________________________


Card Holder Signature __________________________________________________________ Date: ______________________

Signature of agreement: Please retain a copy for your records. You are hereby authorized to reserve the support items for the company/organization listed above with regard to the 2013 ACNS Fall Courses, September 28-29, 2013, at the DoubleTree by Hilton Philadelphia Center City. We understand that the selected grants will be charged at the rates quoted in the support prospectus, with acknowledgement as indicated in the support prospectus. Receipt of payment in full constitutes a confirmation of the selected grant. If grants are not paid in full at time application is submitted, items may be sold to another supporter at the discretion of ACNS.

Print Name: _______________________________________________________________________________________________

Authorized Signature: ___________________________________________________________ Date: ______________________

pleaSe return thiS appliCation with required payment to: American Clinical Neurophysiology Society

Attn:SamanthaSurillo•555E.WellsStreet,Suite1100•Milwaukee,WI53202 Phone:(414)918-9803•Fax:(414)276-3349•E-mail:[email protected]

AC

NS-

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appliCation for exhibit SpaCe(pleaSe print)

Name of Convention: ________________________________________________________________________________________

Dates of Convention: _________________________________________________________________________________________

Exhibit Firm: _______________________________________________________________________________________________

On-Site Contact: ____________________________________________________________________________________________

Order Authorized by: (Please sign) ______________________________________________________________________________

exhibit priCe liSt:

eleCtriC

1. Electrical Fee $50.00 x =

2. Per Amp Charge $ 5.00 x =

3. Quad Box Rental $25.00 x =

4. Extension Cords $25.00 x =

phone line

1. Outside Line $45.00 x = Plus Each Call

2. Wired Internet $100.00 x =

3. Wireless Internet $300.00 x =

miSCellaneouS

1. 6’ Exhibit Table and Cloth $30.00 x _____________________= ____________________________

2. 6’ Exhibit Table, Cloth & Skirt $45.00 x _____________________= ____________________________

3. Brass Easel $10.00 x _____________________= ____________________________

4. Trash Can $ 5.00 x _____________________= ____________________________

5. Delivery of Boxes $ 4.00 per box ________x_______= $___________________________

*note: full payment and Completed appliCation muSt be in one week prior to ConVention*

payment method:

If paying by check, make check payable to Doubletree Hotel Philadelphia

If using credit card please complete information below and send a copy of the front and back of the credit card

Type: CC # Exp

Send appliCation baCk to the Doubletree by Hilton Philadelphia Center City, 237 S. Broad Street, Philadelphia, PA 19107 or fax to (215) 893-1664

AMERICAN CLINICAL NEUROPHYSIOLOGY SOCIETY

2014 Annual Meeting & Courses

AtlAntA FEbRUARY 4-9, 2014 ATLANTA, GA Westin Peachtree Plaza

SAVE the DATE!

www.acns.org

acns fall courses · a a orss ehibit & support prospectus september 28-29, 2013 •...

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