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

Are you a returning sponsor?*	Yes No *
Sponsor level*	Title - $5,000 (Four CE Registrations) Gold - $2,500 (Two CE Registrations) Silver - $1,000 (One CE Registration) Bronze - $500 *
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*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY *
Zip Code*	- ***
Phone Number*	() - ******
Fax	() - ***
Email Address*	*Invalid Email
Total Amount