2021 Ancillary/Affiliate Meeting Space Listing Submission
This form is for organizations who have already contracted space in conjunction to ANESTHESIOLOGY® 2021, October 8 - 12 in San Diego, CA. Your function will be listed on the: Anesthesia-Related Meetings Wall at ANES2020 On the ANESTHESIOLOGY® website At our information desk On the ANESTHESIOLOGY® mobile app
CONTACT INFORMATION
(Fields Marked with * are required)
Ancillary /Affiliate Contact Person
*
Organization/Institution /Company Name
*
Address
*
City
*
State
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Phone
*
Fax
*
Email
*
MEETING/FUNCTION SPECIFICATIONS
Meeting /Function Name
*
Meeting Function - Description/Purpose
*
Meeting Start Date
*
-
Month
-
Day
Year
Date Picker Icon
Meeting Start Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Meeting End Date
*
-
Month
-
Day
Year
Date Picker Icon
Meeting End Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Expected Number of Attendees
*
Meeting Location
*
Please provide hotel, restaurant, or facility name.
Meeting/Function Space Set
*
Conference
Hollow Square
U-Shape
Banquet Rounds
Classroom/Schoolroom
Theatre
Reception
MEETING/FUNCTION TYPE
Type of event:
Committee Meeting
Board Meeting
Alumni Reception
Reception/Dinner
Other
If other, please list type here:
Check here if this meeting/function is educational in nature
Check here if this meeting/function has an invited speaker to present
No
Other
Check here if marketing materials will be produced for this function/meeting. Please Note: ASA requires review of all marketing materials prior to production and distribution for the proposed event
Submit
Should be Empty: