september 22-25 | wichita, ks - wild apricot... · 2016-05-02 · 2016 kpf benefit golf fundraiser...

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Contact: Auburn Packer Director of Operations e: [email protected] p : 785.228.2327 f: 785.228.2511 kansas pharmacists association Vendor prospectus includes Sponsorship & Exhibitor Opportunities #kpha2016 Follow the Annual Meeting @KansasPharmacy Facebook.com/KSPharmacists search for kpha staff stay connected with us! C onnect with others E ducate yourself R epresent your profession 1020 sw fairlawn rd. Topeka, ks 66604 | web: www.ksrx.org Reimagining the Present Advancing as Providers 2016 Annual Meeting & Trade Show September 22-25 | Wichita, kS Wichita Marriott Hotel 9100 Corporate Hills Drive, Wichita, KS 67207

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Page 1: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

Contact: Auburn PackerDirector of Operations e: [email protected]

p: 785.228.2327 f: 785.228.2511

kansas pharmacists associationVendor prospectus

includes Sponsorship & Exhibitor Opportunities

#kpha2016Follow the Annual Meeting

@KansasPharmacyFacebook.com/KSPharmacists search for kpha staff

stay connected with us!

Connect with others

Educate yourself

Representyour profession

1020 sw fairlawn rd. Topeka, ks 66604 | web: www.ksrx.org

Reimagining the Present

Advancing as Providers

2016 Annual Meeting& Trade Show

September 22-25 | Wichita, kSWichita Marriott Hotel

9100 Corporate Hills Drive, Wichita, KS 67207

Page 2: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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Annual Meeting ForecastThursday, Sept. 22nd: Kansas Pharmacy Foundation (KPF) Golf Fundraiser at Willowbend Golf Club during the day with the President’s Reception in the evening at hotel.

Friday, Sept. 23rd: Start of plenary continuing education sessions with the trade show & luncheon following. CE sessions wrap up the day. Political Action Committee event in the evening, as well as social networking fun night.

Saturday, Sept. 24th: CE sessions kick-off the day with the KPhA Annual Meeting over lunch, followed by more CE sessions ending at 5 p.m. KPF Silent Auction bidding starts at 6 p.m. with the KPhA Awards Dinner starting at 7 p.m.

Sunday, Sept. 25th: Last morning of CE, including a Collaborative Practice and Kansas Board of Pharmacy Law Update. Day ends by noon.

The KPhA Annual Meeting and Trade Show is the premier event for Kansas pharmacy professionals from across the state to:

Why you should Attend!

This event provides you with the perfect platform to increase your brand recognition and broadcast services to a targeted audience. You have the opportunity to connect and engage through sponsorships, exhibits, events throughout the weekend and other supporting materials. This event allows you to educate, update and showcase your message to a variety of pharmacy professionals in all practice settings. Enjoy meeting new contacts and strengthening your current relationships. KPhA will be promoting the event through direct mail, email, social media, conference app and on our website, providing your company with great exposure to pharmacists, technicians and pharmacy students throughout the state.

• Connect, network and build relationships • Conduct business• Earn continuing education• Receive special recognition• Learn about new products and services that are available• Have fun with friends and colleagues in the pharmacy profession

Meet us in wichita...Wichita Marriott Hotel (9100 Corporate Hills Drive, Wichita, KS 67207)

Page 3: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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• Recognition as a Gold Sponsor on all conference materials, including event mailer, program booklet, signage at the conference and promotional item (to be determined)

• Recognition in electronic communications, including the conference APP, social media, website & emails

• Recognition from the podium for support and sponsorship throughout the conference• Complimentary Trade Show exhibit space in prime location• Complimentary half-page, color promotion in program booklet• Complimentary registration for two individuals

• Recognition as a Platinum Sponsor on all conference materials, including event mailer, program booklet, signage at the conference and promotional item (to be determined)

• Recognition in electronic communications, including the conference APP, social media, web-site & emails

• Recognition from the podium for support and sponsorship throughout the conference• Complimentary Trade Show exhibit booth in prime location• Complimentary full-page, color promotion in program booklet• Opportunity to address attendees• Complimentary registration for three individuals

PtPlatinum

78

195.08

AuGold

79

196.97

AgSilver

47

107.87

Meal Sponsorship opportunities

If you would like to sponsor a meal (to the left - President’s Reception, PAC event, Fun Night and/or Awards Banquet), belowarethebenefitsforbeingasponsor:

Awards Banquet Sponsor | $1,500 Saturday, Sept. 24 (3 Available)

President's Reception Sponsor $1,000 - Thursday, Sept. 22 (3 Available)

PAC Event Sponsor | $1,000Friday, Sept. 23 (3 Available)

Annual Meeting Sponsorship opportunities

Platinum level - $10,000

gold level - $5,000

Silver level - $2,500• Recognition as a Silver Sponsor on all conference materials, including event mailer,

program booklet, signage at the conference and promotional item (to be determined)• Recognition in electronic communications, including the conference APP, social media,

website & emails• Recognition from the podium for support and sponsorship throughout the conference• Complimentary Trade Show exhibit space in prime location• Complimentary quarter-page, color promotion in program booklet • Complimentary registration for one individual

Fun night sponsor | $500Friday, Sept. 23 (4 Available)

• Signage at entrance of event• Verbal recognition at event• 2 tickets to attend event• Recognition in conference mailer and program• Recognition in electronic communications, including

the conference APP, social media, website & emails

Break Sponsor | $300

• Signage on break table• Recognition in conference program, on KPhA Annual Meeting webpage and conference APP

Page 4: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

Conference Tote Bag Sponsor (1 Available) - $1,500 | Conference Lanyard Sponsor (1 Available) - $1,500

• Recognition in conference program & APP• Company recognition on KPhA Annual Meeting Webpage &

conference promotional emails• One table & two chairs• One full conference registration• Lunch and name badges for 2 representatives (extra tickets are $30)• Tote bag insert (Must be provided by Sept. 1, 2016 - 175 copies)

$1,000 | Vendors$300 | Educators*

*Only available to nonprofit organizations & established educational institutions.

NOTE: Electricity is NOT included with exhibitor fee. The cost of electricity is as follows: Up to 15 Amps/110 Volts - $15 | Up to 16-20 Amps/110 Volts - $20 | Up to 30 Amps/110 Volts - $30If you need more electricity than what is mentioned above, please contact Auburn Packer.

The Silent Auction is a fundraiser for the Kansas Pharmacy Foundation. Bring a Silent Auction item and showcase your donation at your booth during the Trade Show. The Silent Auction will take place Saturday, Sept. 24 at 6 p.m. If you plan to bring an item, please email Kelly Rockers ([email protected]) a picture, description and value of item by August 22. If you are not attending the auction but would like to contribute, please have the contribution shipped to the KPhA office by August 22 (1020 SW Fairlawn Road Topeka, KS 66604). Monetary donations must be made payable to the Kansas Pharmacy Foundation.

Silent Auction Contributor - Unlimited | Min. Value $100

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The Trade Show will be conducted on Friday, September 24 from 11:30 a.m. - 2:30 p.m. at the Wichita Marriott Hotel. This is an exclusive Trade Show time with no other events scheduled. Lunch will be provided during this time. Exhibitors may register and begin setting up Friday morning, starting at 8 a.m. Deadline to register to be included in the conference program and APP is Monday, August 15, 2016.

NOTE: Payment and logos are due by June 30, 2016

Anticipated Trade Show attendance is 100-150 people.

Join KPhA & receive a discount as an exhibitor!• Professional Member - $850/booth• Bronze Corporate Member - $850/booth• Silver Corporate Member - $800/booth• Gold Corporate Member - $750/booth• Platinum Corporate Member - Complimentary• Diamond Elite Corporate Member - Complimentary

App sponsor - $1,500 - 2 Available

KPhA will be developing a conference APP again this year. To view the conference APP from last year, go to www.kww.net/mapc. The APP was a great resource to attendees last year and was utilized very well. Belowarethebenefitsforbeingasponsor:• Prime placement of company logo on the app with recognition of your sponsorship• Recognition in conference mailer, program and on signage• Recognition in electronic communications, including emails, social media & website• Recognition on materials promoting the use and download of the APP

Be an exhibitor - friday only

exhibit fee includes:

If you are interested in joining KPhA or would like more information, please contact Auburn Packer. E: [email protected] P: 785.228.2327 or go to the KPhA website at www.KSRx.org

Other Sponsorship Opportunities

Meeting attendees will receive a program booklet containing the schedule of events, a listing of exhibitors and sponsors, meeting details and promotional pages. Heighten your visibility to all participants by having a promotion in the program booklet. Email promotions to [email protected] by Monday, August 15, 2016. Prices for promotions are on the registration page.

• Logo displayed on bag • Logo displayed on lanyard

Program booklet promotions

Page 5: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

2016 KPF Benefit Golf Fundraiser

Golf sponsorships and donations are available to any interested party (individuals, groups and businesses). All proceeds benefit the Kansas Pharmacy Foundation (KPF). Please fill out the form on the back of this page to register for participation or sponsorship at the golf fundraiser. For questions, please contact Kelly Rockers. E: [email protected] P: 785.228.2327.

Where: Willowbend Golf Club 8001 E Mulberry Dr., Wichita, KS 67226 | 316.636.4653Date: Thursday, Sept. 22, 2016Time: Registration 8:30 a.m. | Scramble 9 a.m. - 2 p.m.

Be a ParticipantIndividual Player | $150 Team Players | $600 • One individual player• Green fees, golf cart & lunch buffet

• Four individual players• Green fees, golf cart & lunch buffet

Be a SponsorDrink Cart Sponsor$1,000 | One Available

Lunch Sponsor $1,000 | One Available

Sponsor a Hole $150 | 17 Available

• Recognition at hole• Recognition in conference program• Recognition on KPhA Annual Meeting golf webpage

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SOLD

• Signage at Golf Fundraiser registration• Drink cart signage• Registration for 2 golfers• Recognition in conference materials• Recognition in electronic communications,

including the conference APP, social media, KPhA Annual Meeting golf webpage & emails

• Signage at Golf Fundraiser registration• Signage at lunch buffet• Registration for 2 golfers• Recognition in conference materials• Recognition in electronic communications,

including the conference APP, social media, KPhA Annual Meeting golf webpage & emails

Help fund the prizes given away to the top winners!

• Signage at Golf Fundraiser registration• Verbal recognition when prizes are given

away• One player registration• Recognition in conference materials• Recognition on KPhA Annual Meeting

golf webpage, emails and conference APP

ThepurposeoftheKansasPharmacyFoundationistoprovidesupportforscientificandeducationalactivities,which promote the welfare and integrity of the profession of pharmacy and the enhancement of public health.

Mission of KPF

“ “

Prize sponsor $500 | One Available

Golf Ball Sponsor $500 | One Available• Company logo on golf ball• Signage at Golf Fundraiser registration• One player registration• Recognition in conference materials• Recognition on KPhA Annual Meeting golf

webpage, emails and conference APPNote: Logo due to KPhA by June 30, 2016

Hole-in-one sponsor

Mini Golf Ball Marking Pen sponsor $250 | One Available

Tee Sponsor$250 | One Available

• Company logo on tee• Signage at Golf Fundraiser

registration• One player registration• Recognition in conference

program• Recognition on KPhA Annual

Meeting golf webpage, emails and conference APP

Note: Logo due to KPhA by June 30, 2016

• Company logo on marker• Signage at Golf Fundraiser

registration• One player registration• Recognition in conference

program• Recognition on KPhA Annual

Meeting golf webpage, emails and conference APP

Note: Logo due to KPhA by June 30, 2016

Lunch will be provided between 1 & 2 p.m.

Page 6: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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Prize Sponsor ($500)

Hole Sponsor ($150)

Golf Registration Form

Individual Name:

Contact Phone: Contact Email:

Address:

City: State: Zip:

Individual Player ($150) 4 Player Teams ($600)

NOTE: Please include the names of the person(s) on your team in the section below.

I cannot play in the tournament, but enclosed is my donation of $150 as an Individual Sponsor.

Please provide the names of the person(s) on your team, or on the team you are sponsoring. 1. _______________________________________________________________________________________________ 2. _______________________________________________________________________________________________3. _______________________________________________________________________________________________ 4. _______________________________________________________________________________________________

Sponsorships

Drink Cart Sponsor ($1,000)

Primary Contact:

Company Name:

Contact Phone: Contact Email:

Total Amount = Payment Method

Check - Make payable to the Kansas Pharmacy FoundationCard - MC / VISA / AMEX / DISCOVER

Billing Address:

City: State: Zip:

Name as it appears on card:

Card Number:

Security Code: Exp. Date: Email:

Authorized Signature:

Billing phone number of Card Holder:

NOTE: If you are also being a Sponsor or Exhibitor for the Annual Meeting, please skip this payment form and go to the Billing Form at the end of this packet to provide complete payment information for everything.

Register Online! Go to www.ksrx.org

Mail: KPhA | 1020 SW Fairlawn Rd | Topeka, KS 66604 | Email: [email protected] | Fax: 785.228.2511

Golf Ball Sponsor ($500)

Mini Golf Ball Marking Pen Sponsor ($250) Tee Sponsor ($250)

Lunch Sponsor ($1,000)

Page 7: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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Exhibitor Rules & RegulationsTrade Show Exhibit SiteThe trade show will be held at the Wichita Marriott HotelAddress: 9100 E Corporate Hills Dr. Wichita, KS 67207P: 316.651.0333 | F: 316.651.0634

Trade Show Hours11:30 a.m. - 2:30 p.m.Friday, Sept. 23rd, 2016

Electrical & Special NeedsPower to the exhibit space is an extra fee. Please refer to page 4 for exact costs and request the electricity you prefer on contract. If electricity was not selected and the exhibitor needs electricity on the day of the trade show, exhibitors will be charged $50. For additional display equipment or special equipment needs, contact Auburn Packer.

Display Set Up & DismantlingExhibitors may register and set up their exhibits any time between 8 and 11:30 a.m. on Friday, Sept. 23, 2016. The Trade Show is scheduled to start at 11:30 a.m. with lunch included. Display dismantling must be completed by 5 p.m. Sept. 23.

Payment of Exhibitor FeeTo reserve exhibit space, a deposit of one-half (50%) of the grand total exhibitor/sponsorship fee is due with completed contract. Remaining balance of exhibitor fee plus any additional expenses incurred is due by September 19, 2016.

Late Fees, Refunds and Cancellation PolicyAugust 15, 2016 is the deadline for exhibitors to be guaranteed inclusion in the conference program and APP. Exhibitors who register after August 15 are not guaranteed inclusion in the conference program or APP. Absolute deadline for exhibit registration is August 31, 2016. Contracts received after August 31, 2016 will be charged at late fee of $100 and will not be listed in program materials. Cancellations made before August 31, 2016 will receive a 50% refund if a written request is received by KPhA prior to August 31, 2016. Cancellations made after this date will not be eligible for a refund. Any refunds due will be processed within thirty days of receipt of written cancellation.

Promotional MaterialsIf you are interested in a promotional item, payment and logos are due by June 30.

Annual Meeting RegistrationThe number of complimentary registrations provided to sponsors/exhibitors is included in the fee. Please list and provide all contact details of individuals attending the conference. Shipment of MaterialsIt will cost:• Boxes (>3 lbs.) $5 per box • Boxes (<3 lbs.) $10 per box• Booths & Trunks

$30 per Booth, Trunk (regardless of size/weight)

• Crates [1ft. – 5ft.] $75 per crate (regardless of size/weight)

• Crates [6 ft. – 7ft] $100 per crate (regardless of size/weight)

• Crates [7 ft. & up] $150 per crate(regardless of size/weight)

• Storage Fee [over (3) days] $25 per day

Exhibitors wanting to ship display materials to the hotel must mark their packages as follows:

Wichita Marriott HotelKPhA Trade Show {Vendor Name}Attn: Auburn Packer/Sept. 21, 20169100 E. Corporate Hills DriveWichita, KS 67207Hotel Contact Name: Jennifer Captain

If multiple boxes, please list as “Box 1 of 4, Box 2 of 4, etc.”

Due to limited storage space, the hotel will accept shipments only (3) days prior to event. A $25/day storage fee will be added to each package arriving more than (3) days prior event. The hotel will provide delivery to the event location on date of setup. Exhibitors are responsible for all unpacking and setup of exhibit items. After event, Exhibitor will be responsible for dismantling, repacking and sealing of outbound shipments. Package/Box pickup service is provided by FedEx. Exhibitor is responsible for own shipping pickup fees if using another shipping service. All outbound shipments will require completed shipping documents, including billing account numbers. Hotel will provide pickup from your event location and secure in their receiving department for pickup by designated shipping vendor.

Any special shipping and receiving requirements may be directed specifically to James Wallace, Shipping & Receiving Manager at (316) 651-0333 ext. 6124 before 2:30pm. After 2:30pm, please leave a message for John Caskey, Guest Liaison Manager at (316) 651-0333 ext. 6149.

Hotel ReservationsExhibitors are responsible for their own hotel accommodations. KPhA Annual Meeting participants are entitled to receive the special rate of $107 plus tax, per night, single/double occupancy. To ensure a room at this rate, make hotel reservations by Sept. 7, 2016 by calling the Wichita Marriott Hotel at 316.651.0333.

LiabilityThe individual/exhibitor on signing this contract of agreement, expressly releases the Kansas Pharmacists Association, their members and representatives, from any and all claims of injury, loss or damage that may occur to the exhibitor, the exhibitor’s employees or the exhibitors property from any cause whatsoever. Exhibitor assumes complete responsibility and liability to pay for any and all damages to property owned by the Wichita Marriott Hotel, its owners or managers, which results from any act of omission of Exhibitor. Exhibitor agrees to defend, indemnify, and hold harmless the Wichita Marriott Hotel, KPhA members and representatives, owners, managers, officers or directors, agents, employees, subsidiaries and affiliates, from any damages or charges resulting from Exhibitor’s use of the property. Exhibitor’s liability shall include all losses, costs, damages, or expenses (including attorney’s fees) arising from or out of or by reason of any accident or bodily injury or other occurrences to any person or persons, including the Exhibitor, its agents, employees, and business invitees which arise from or out of the Exhibitor’s occupancy and use of the exhibition premises, the Wichita Marriott Hotel, or any part thereof.

The Wichita Marriott Hotel takes no responsibility for damage to or loss of any items left in the exhibit hall prior to, during and/or following any function and all such responsibility and liability is specifically disclaimed. The Wichita Marriott Hotel makes no and specifically disclaims any and all warranties or representations to the client or guest(s) other than those printed herein.

Auburn [email protected] | 785.228.2327

Please Contact:

For Questions/Concerns

Page 8: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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KPhA Sponsor & Exhibitor ContractContracts are due by August 15, 2016

The sponsorships and exhibit space are given on a first come, first served basis. Please complete the contract in its entirety to guarantee inclusion in all marketing materials corresponding with your committed sponsorship/exhibit level. Sponsors and exhibitors are responsible for providing logos and artwork for advertisements. KPhA reserves the right to reject any materials that they do not see fit for the annual meeting and trade show. Please return completed forms by mail, email, online or fax. Mail: Kansas Pharmacists Association | 1020 SW Fairlawn Rd | Topeka, KS 66604Email: [email protected] | Fax: 785.228.2511 | Online: Go to www.ksrx.orgDirect any questions/concerns to: Auburn Packer, Director of Operations at KPhA

Guidelines

Primary Contact:

Company Name:

Contact Phone: Contact Email:

Address:

City: State: Zip:

Cont.

Program Information

Company Name:

Address:

City: State: Zip:

Conference Sponsorships

Meal Sponsorships

Exhibitor

Other SponsorshipsPrint, Online & Promotional Items

If you are a KPhA member and receive a discount for exhibiting, please mark vendor on this page and put the correct total of discount on the payment page. If you do not know it, KPhA will make sure to charge you the correct amount.

Company Email:

Company Phone: Company Fax:

Company Website:

Facebook Page: Twitter Handle:

Platinum ($10,000) Gold ($5,000) Silver ($2,500)

Full page color promo ($800)1/2 page color promo ($400)1/4 page color promo ($200)

Register Online! Go to www.ksrx.org

KPhA Banquet Dinner ($1,500) President’s Reception ($1,000)Break Sponsor ($300)Fun Night Sponsor ($500)

PAC Event Sponsor ($1,000)

Vendor ($1,000) Educator ($300) Electricity Yes No $

How much?

Silent Auction Contribution ($100)

Conference Tote Bag ($1,500)Conference Lanyard ($1,500)

APP Sponsor ($1,500)

Added lunch ticket ($30) #

Please see page 5 for golf fundraiser sponsorships.

Page 9: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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Conference Materials (Logos & Promotional Pages)

• Please submit an .eps file of your logo in both color and black & white when you submit your contract if possible.• Logos for promotional items are due by June 30, 2016. Promotional pages are due by August 15, 2016. Pages

not received by this date, will not be guaranteed placement in printed materials• Tote bag inserts must be provided in bulk (175 copies) to the KPhA office by Sept. 1, 2016. Materials need to be

shipped to: Kansas Pharmacists Association | 1020 SW Fairlawn Road | Topeka, KS 66604

Exhibitor Personnel/Complimentary Conference Registration Info

Provide the name(s) of the exhibitor or complimentary conference registration attendee below. Complimentary conference registration is provided with certain sponsorships and with exhibitor registration. Complimentary registration(s) are only given to the people who are representing the Sponsor or Exhibitor at the booth during the trade show and would like to attend the annual meeting as well.

Exhibitor Registrant 1

Name:

Company Name:

Contact Phone: Contact Email:

Address:

City: State: Zip:

Name:

Company Name:

Contact Phone: Contact Email:

Address:

City: State: Zip:

Exhibitor Registrant 2

DOB: (MM/DD) NABP/CPE #: (Only needed if attending for CE credit)

Competitors you do not want to be next to:

Company:

Company:

Silent Auction Donation:

Donated Item(s):

DOB: (MM/DD) NABP/CPE #: (Only needed if attending for CE credit)

If you plan to bring an item, please email Kelly Rockers ([email protected]) a picture, description and value of item by August 22.

Page 10: September 22-25 | Wichita, kS - Wild Apricot... · 2016-05-02 · 2016 KPF Benefit Golf Fundraiser Golf sponsorships and donations are available to any interested party (individuals,

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Sponsor/Exhibit/Promotion Amount =

Check - Make payable to the Kansas Pharmacists Association (1020 SW Fairlawn Rd. Topeka, KS, 66604)

Card - MC / VISA / AMEX / DISCOVER

(50% deposit is due with contract. Full payment is due by September 19, 2016)

To validate this contract & reserve a sponsorship opportunity or an exhibitor space:1) Complete all information above pertaining to sponsorship and exhibitor aspects that sponsor/exhibitor wishes to reserve.2) Sponsor/Exhibitor understands and agrees to comply by the rules and regulations of this contract as expressed on page 7 (Please pass information onto personnel who will man the booth).3) Terms and conditions: The exhibitor/sponsor listed above agrees that the Kansas Pharmacists Association is authorized to reserve exhibit space at the Wichita Marriott Hotel for use by the above company/organization during the conference 9/22-25, 2016, and acknowledges receipt of.4) Read and acknowledges the important dates for items to be due.5) Completed & signed contract must be accompanied with a 50% deposit payment.

By signing, I accept and agree to the terms, conditions, rules and regulations of this contract:

Authorized Signature: Date:Title:

ForOfficeUseOnlyDate Received: Payment Recorded: Invoiced after conference:Logo Received:

Notes:

Billing/Payment Form

Golf Fundraiser Amount =Grand Total =Amount Enclosed =

Billing Address:

City: State: Zip:

Name as it appears on card:

Card Number:

Security Code: Exp. Date: Email:

Authorized Signature:

Billing Phone number of Card Holder:

Payment Method

Register Online! Go to www.ksrx.org