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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

Are you a returning sponsor? *

Sponsor level *

Please list names of complimentary CE registrant(s) with discipline *

Sponsor / Exhibitor name *

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