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Sponsor Commitment Form - Check

Checks should be made payable to:
The MIND Center

Please submit payment and commitment form to:
Kathy Van Cleave
The MIND Center
University of Mississippi Medical Center
2500 N. State St.
Jackson, MS 39216 

For questions, please contact us:
email: mindcenter@umc.edu
Phone: 601.815.4237
Fax: 601.213.4066

* - Required Fields

Sponsor level*
Are you a returning sponsor?*  
Discount Code* 
Please list names of complimentary CE registrant(s) with discipline* 
Sponsor / Exhibitor name* 
Organization name as it should appear in conference materials* 
Organization name as it should appear in conference materials* 
Contact person* 
First Name* 
Last Name* 
Street Address* 
City* 
State*
Zip Code* -  
Phone Number*() -    
Fax() -
Email Address* 
Total Amount
Alzheimer's Conference Sponsor*