KU Medical Center * Division of Continuing Education * 3901 Rainbow Blvd. * Kansas City

KU Medical Center | Midwest Stem Cell Therapy Center | 3901 Rainbow Blvd, Mail Stop 1075 | Kansas City, KS 66160 Phone: (913) 945 7024 | www.kumc.edu/msctc

Contributor Application 4th Annual Midwest Conference on Cell Therapy & Regenerative Medicine Friday, September 16 - Saturday, September 17, 2015 Sheraton Overland Park | 6100 College Boulevard | Overland Park, KS 66211

CONTRIBUTION LEVELS All contributions at all levels (Supporter, Partner, Leader, Premier, General) are recognized on general meeting signage and in the print program.

Supporter - $500 . May provide printed materials for 200 participants.*

Partner - $1,000 . May provide printed materials for 200 participants.* . Allowed one complimentary registration . Acknowledgement on social media outlets . Acknowledgement on slides between meeting sessions

Leader - $2,000 . May provide printed materials for 200 participants.* . Allowed two complimentary registrations . Signage at Abstracts Wine & Cheese Reception (one opening available)** . Signage at morning or afternoon break (4 options available)** . Acknowledgement on social media outlets . Acknowledgement on slides between meeting sessions

Premier - $5,000 . May provide printed materials for 200 participants.* . Allowed three complimentary registrations . Signage at conference meal (4 options available)** . Signage at Speakers Dinner (one opening available)** . Acknowledgement on social media outlets . Acknowledgement on slides between meeting sessions

General Meeting Contribution – Under $500 Those with an interest in supporting the Midwest Conference on Cell Therapy & Regenerative Medicine may provide an unrestricted donation. These contributions cover non-CME expenses not related to a specific event or item at the meeting. Contribution Amount: $

*Deadline to submit printed materials is August 29, 2016. Materials are to be available outside of the General Session Area. **Email Pauline Horton ([email protected]) for available options.

1 PAYMENT To confirm your contribution, email the completed Contributor form to Pauline Horton at [email protected]. Fee must be paid in advance of the conference. Confirmation sent once payment is received. Check Payable to "KU Endowment” Send check with copy of this form to: Pauline Horton Midwest Stem Cell Therapy Center The University of Kansas Medical Center 3901 Rainbow Blvd, Mail Stop 1075 Kansas City, Kansas 66160

Email address to which receipt should be sent:

PLEASE PRINT 1. Company Name:

Business Office Contact Person: Job Title (For billing purposes)

Corporate Business Address: City, State, Zip

Phone Fax Email

2. PERSON(S) REPRESENTING COMPANY AT EXHIBIT BOOTH: (PLEASE PRINT)

Name Job Title

Any Additional company representatives must register online and pay the “Industry Representative” registration fee.

3. Sign here to acknowledge the following statement. We agree to abide all requirements as outlined on this application and in the prospectus. Proprietary company representatives may not engage in sales activities where the educational activity occurs.

Authorized Signature Title Date

For MSCTC Office Use Only:  Application Received  Payment Received Rev. 12/15 Project #:  Check submitted to Institutional Finance _____

Send completed application to Pauline Horton at [email protected].