Application for Partner Exhibit Space

Application for Partner Exhibit Space April 22, 2015 ~ Overland Park Convention Center

Please reserve exhibit space for our company at Medical Group Management Association of Greater Kansas City’s 2015 Annual Meeting at the Overland Park Convention Center in Kansas City, Kansas. If none of the six exhibit spaces we have requested are available, we request the (provider) to assign to our company the best available space.

We understand that this application becomes a contract when signed by us and accepted by the Medical Group Management Association of Greater Kansas City. We agree to abide by the conditions of the contract and regulations published in the Prospectus and by all conditions under which space at the Overland Park Convention Center is leased to the Medical Group Management Association of Greater Kansas City. We accept responsibility for informing all our employees and agents of these conditions and agree that they will abide by them. We further understand the penalties that may be assessed if we are in violation of these conditions.

We understand that the application deadline is March 25, 2015. Space will be assigned on March 30, 2015. We further understand that if our application is sent after initial space assignment, full payment must accompany the application, unless prior arrangements have been made with the Exhibit Manager. We are aware that any information received by the Medical Group Management Association of Greater Kansas City after April 8, 2015 will not be included in the official program.

We understand that any product(s) we will be promoting through our exhibit that require approval by the Food and Drug Administration (FDA) must receive this approval before our company will be eligible to exhibit. By signing this application, we are signifying that FDA approval has been granted.

We understand that selling and order-taking will be allowed on-site. We also understand that we are responsible for adhering to business license and sales tax regulations for the State of Kansas City.

We understand that our exhibit is designed for the display and demonstration of products and services relating to the practice and advancement of the art and science of medicine, and the professional education of the members of the Medical Group Management Association of Greater Kansas City. To this end the Medical Group Management Association of Greater Kansas City may forbid installation or request removal of discontinuance of any exhibit or promotion, wholly or in part, that in its opinion is not in keeping with the character and purpose of the Medical Group Management Association of Greater Kansas City.

We agree to be responsible for our own property through insurance or self-insurance and shall hold harmless each of the other parties and for any and all damage caused by theft and those perils normally covered by a fire and extended coverage policy.

We understand that the Medical Group Management Association of Greater Kansas City reserves the right to change or modify any rule or regulation in the best interest of the Kansas City Society of Ophthalmology and Otolaryngology.

Please complete application on reverse side Application for Partner Exhibit Space April 22, 2015 ~ Overland Park Convention Center

I have read and understand the conditions listed on both sides of this application. By signing below I am indicating my company’s agreement to become a Partner at Medical Group Management Association of Greater Kansas City’s Annual Meeting and be bound by any and all such conditions and regulations.

(PLEASE TYPE)\

Company Name Address City/State/Zip Tele Fax Contact Name Title Address Email City/State/Zip Tele Fax Signature Date

Indicate booth locations in order of preference by booth number. 1st 2nd 3rd 4th 5th 6th

We would like to donate a door prize for the raffle: Yes No If yes please provide item description:

Payment Information Please TYPE Payment Information

Cost Per Booth: $ Name as it appears on card Total number of booths requested # Address Total cost of booths requested $ City/State/Zip Indicate Payment Method: Check Account Number: Make check payable to: MGMA-GKC MasterCard Expiration Date: Security Code: VISA Signature Official Program Description Partner Names for Badges Please TYPE a description of your company to appear in the If known, please TYPE the names of company representatives Official Program. Description of company or product, not to to be used on exhibit badges. exceed 50 words. Please fill in all areas that will be helpful to physicians. Use separate sheet if necessary.

General Product Line Company Name Address City/State/Zip Telephone Fax Website ______

For Office Use Only Return your application to: Date Application Received Check Number MGMA-GKC Invoice Number 315 Nichols Road, Suite 250 Booth Space Assigned Kansas City, MO 64112 Date Received Full Payment Fax: 816.531.8438 Amount Received $ Email: [email protected] Check Number