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Name of Representative(s) staffing the exhibitor platform:

Name of Attendee(s) with complimentary registration per Exhibitor Support Level:

Products, supplies, equipment and/or services to be displayed:

As an authorized representative of the company listed above, I understand that:

  1. Reasonable security measures will be taken for hybrid exhibits, but UT Health San Antonio accepts no responsibility for any exhibit contents, instruments, or equipment.

  2. Exhibitors may not assign, sublet or apportion a virtual space allotted, or exhibit any goods other than those manufactured or handled by the exhibitor in the regular course of their business.

  3. Exhibit payment does not support education and is only for the use of the exhibit space.

By typing my name above, i am electronically signing this form.

If signature is from other than Representative listed above, please provide information below:

Make checks payable to: UTHSCSA CME - 170884
7703 Floyd Curl Drive, Mail Code 7980, San Antonio, TX78229-3900 Federal Tax ID# 74-1586031

Credit Card
We will contact you for credit card information.

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