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Our Facility
Request an Event
Contact
Request an Event
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Requestor Information
Today's Date
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MM slash DD slash YYYY
Company /Institution
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Requestor Name
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Requestor Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
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Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
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Bosnia and Herzegovina
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Bouvet Island
Brazil
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Bulgaria
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Burundi
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Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
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Cook Islands
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Croatia
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Curaçao
Cyprus
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Gabon
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Ghana
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Hungary
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India
Indonesia
Iran
Iraq
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Isle of Man
Israel
Italy
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Japan
Jersey
Jordan
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Kenya
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Korea, Republic of
Kuwait
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Lao People's Democratic Republic
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Lebanon
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Libya
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Nigeria
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Panama
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Poland
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Saint Lucia
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Samoa
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Serbia
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Switzerland
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Thailand
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Virgin Islands, U.S.
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Email
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Phone
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Event Information
First Option of Event Date
*
MM slash DD slash YYYY
Second Option of Event Date
*
MM slash DD slash YYYY
Duration of Event & Time Frame
*
Hours/ Days Needed for Set Up
*
Additional fees may be applied depending on timeframe.
Description of Event
*
Estimated Number of Attendees
*
Include participants, faculty, and business associates.
Facilities Needed
*
Auditorium
Board Room
Bio-skills Lab
Conference Room
Check all that apply.
Catering
*
Breakfast
Lunch
Dinner
Refreshments/Snacks
Check all that apply.
Bio-skills
For questions that do not apply, please fill N/A.
Number of Stations
*
Number of Specimens
*
Type of Tissue
*
Positioning of Tissue
*
Tissue Supplier
*
Medical Academic Center to Supply
Requestor to Suppy
Description of Supplier
*
Number of C-arms/ Techs
*
Arthroscopy Towers
*
Suction Units
*
Headlamps/Lights
*
Light Sources
*
Cautery/Bovie Units
*
Lami Trays
*
Drills
*
Lead Aprons/Thyroid Shields
*
Other
*
AV Needs
For questions that do not apply, please fill N/A.
Lavalier/Wireless Microphone
*
Video Confrencing
*
Recording 3D or 2D
*
Ultrasound Machine
Microscope
Arthroscopy Tower
C-Arm
Auditorium
Video Streaming Live Procedures
*
Internally
Externally
Laptop Computer
*
Yes
No
If Utilizing Your Own, What is the Output?
*
VGA
HDMI
Type-C
N/A
Image Capturing on Monitors in Bio-skills Lab
*
Other
*
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