Rural Health Education and Services

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Date

October 08, 2009

School of Medicine-Wichita
Wichita, KS

October 29, 2009

The University of Kansas Medical Center
Kansas City, KS

I would like to register for both conferences.

INSTRUCTIONS: Please complete and submit by September 15, 2009 with your exhibit fee of Three Hundred Dollars ($300) for space for both events or Two Hundred Fifty Dollars ($250) for one event. Please mail payment to The University of Kansas School of Medicine-Wichita, Rural Health Education and Services, 1010 N. Kansas, Suite 3026, Wichita, Kansas, 67214-3199. You will receive space confirmation on or before September 30, 2009. Please make checks payable to The University of Kansas Medical Center.

AGREEMENT: The undersigned hereby makes application for exhibitor space at the Kansas Career Opportunities event for 2009. The terms and conditions set forth in the Exhibit Information and Regulations, which is hereby made part of this agreement govern this agreement by reference. Acceptance of this application by KUMC constitutes a binding agreement between the KUMC and exhibitor.

Organization & Authorizing Individual

Organization:

Authorizing Name:

Title

Phone:

Primary Contact (will receive all future event information.)

**Please list information below as you would like it to appear in the program.**

Contact Name:

Address:

City/State/Zip:

Phone:

Fax:

Email:

Website:

Company Description

**Please describe your company in 100 words or less for the participant booklets that will be distributed to the attending medical, nursing, and allied health students, resident physicians and other health care professionals on the day of the event. **

I would like to use the facility description from KCO 2008.

Exhibit Representatives Names - Wichita, Oct. 08th

(1):

(2):

(3) - @ $25.00:

(4) - @ $25.00:

(5) - @ $25.00:

Exhibit Representatives Names- Kansas City, Oct. 29th

(1):

(2):

(3) - @ $25.00:

(4) - @ $25.00:

(5) - @ $25.00:

Registration Fee

Enter YES:

Registration fee has been mailed to 1010 N. Kansas, Suite 3026, Wichita, KS 67214. Please make checks payable to The University of Kansas Medical Center.

Regulations and Information

Enter YES:

Please click here to read our event Information and Regulations, and then enter "YES" in the box declaring you have reviewed them.