Vendor/Exhibitor Application SMC Doulas Conference: Vendor and Exhibitor Form [hr]Vendor and Exhibitor InformationI am applying to participate as a:(Required) Vendor Exhibitor Are you a conference sponsor?(Required) Yes No Contact InformationYou can have up to two people at your table. Each contact will receive a badge to wear when onsite at the conference. The badge provides access to the Vendor and Exhibitor area during set-up, open hours, and break-down.Full Name of Primary Contact: First Last Business Name(Required) Legal Business Name Business Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)Full Name of Secondary Contact: First Last Do you give permission for pictures of your booth at the ABMC to be used on our website and Facebook page for promotional purposes?* Yes No Business DescriptionDescribe specific products/materials that you propose to exhibit at the conference:(Required)Be sure to include all products that you intend to exhibit, sell, or give way, including promotional materials. We reserve the right to deny further participation to vendors and exhibitors who sell, exhibit or market products that have not been disclosed on this form.Describe specific products/materials that you propose to sell at the conference.(Required)Be sure to include all products that you intend to sell or give way, including promotional materials. We reserve the right to deny further participation to vendors and exhibitors who sell, exhibit or market products that have not been disclosed on this form.Equipment: Included and OptionalThe conference will provide 1 6-foot table, 1 6-foot table cloth, and 2 chairs. You are welcome to provide your own additional equipment within the allocated space. Generators, heating vents, and hazardous equipment are prohibited. . EQUIPMENT TYPE COST 6-Foot Table x1 Included- $0 Tablecloth x1 Included- $0 Chair x2 Included- $0 Outlets x2 Not Included-$20 If you plan to bring additional equipment, please list your items: Media Release and Consent(Required)I hereby agree and give my permission for Shafia Monroe Consulting (SMC) to record, film, photograph, audiotape or videotape myself(hereinafter collectively referred to as “Works”) and to display, publish or distribute these Works for the purpose of publishing, posting on Shafia Monroe Consulting websites including shafiamonroe.com, smcdoulas.com and conference.smcdoulas.com and posting on Shafia Monroe Consulting social media sites. I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or unknown, and I waive any right to any royalties related to the use of these Works. I understand that the Works may appear in electronic form on the internet or in other publications outside of the Shafia Monroe Consulting’s control. I agree that I will not hold the Shafia Monroe Consulting responsible for any harm that may arise from such unauthorized reproduction. I hereby consent to the use of my personal photograph and photographs provided and grant permission to SMC to the rights of the images, without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. My personal photograph and photographs, photographic images, audio recordings, and video recordings may be used by SMC for the following purposes: • educational presentations and publications • informational presentations and publications • online materials developed by SMC • Program promotion print and social media I will be consulted about the use of the photographs for any purpose other than those listed above. By signing this release, I agree photographic images, audio recordings, and video recordings of me may be electronically displayed via the Internet on the SMC website and SMC Facebook Page and other SMC social media Pages. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release all claims against any person or company utilizing this material for educational or informational purposes. I agree to consent the Media ReleaseWhat Day(s) Will You Vend?(Required)Sept. 16th: $175Sept. 17th: $175Sept. 16th & 17th: $300What Day(s) Will You Vend?(Required)Sept. 16th: $150Sept. 17th: $150Sept. 16th & 17th: $300What Day(s) Will You Exhibit?(Required)Sept. 16th: $150Sept 17th: $150Sept. 16th & 17th: $250What Day(s) Will You Exhibit?(Required)Sept. 16th: $125Sept. 17th: $125Sept. 16th & 17th: $200Total Payment Method*PayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.