AmericanCollegeofMedicalGenetics and Genomics

MAILINGLISTRENTALORDERFORM

1.Checkthetypeofmemberyouwishtotarget.Alist and breakdownofmemberscanbefoundbelow.ACMG only rents postal addresses. Email lists are not available for rental. Select your targetmembercategory(ies).Youmaychoosemorethanoneor chooseallACMGMembersforacompletelist.Ifnopreferenceis indicated,youwillreceiveallACMGMembers.(Thereis no pricereductionforanorderofselectedmembersas opposedtoallmembers.) The address filewill be provided in an excel format.

I.Makesureyouspecifyhowyouwantyouraddressessorted.Check“zipcodeorder”or“alphabetical order”tospecify.Ifnoselectionismade,yourorderwillbesortedinzipcodeorder.

2.Select your ACMG Member/Corporate Sponsor status.

ACMG MembersandcorporatesponsorsofACMGFoundationreceive20%offthetotalpurchaseprice.CompaniesinterestedinCorporateSponsorshipoftheACMGFoundationshouldcontact:

Barbara O’Reilly

American College of Medical Genetics & Genomics Foundation

7220WisconsinAvenue,Suite300

Bethesda,MD20814

Phone(301)718-20814 Fax:(301)718-9604

3.Completetheorderform.Yourordermaybesubmittedviaemail,faxorpostalmail.Sendcompletedformandpayment, togetherwithasampleofthematerialsyouwishtodistributeto:

AmericanCollegeofMedicalGenetics & Genomics

7220WisconsinAvenue,Suite300

Bethesda,MD20814

Phone(301)718-9603Fax:(301)718-9604

Your file will be emailed to you within 10 business days.

OF

AS

1683 / AllACMGMembers / 67 / AffiliateSpecialistMembers
656 / MDFellowsUS/Canada/Foreign / 21 / AffiliateMembers
492 / PhDFellowsUS/Canada/Foreign / 102 / TraineeMembers
185 / AssociateMembers(Counselors) / 93 / Emeritus/HonoraryMembers
39 / CorrespondingMembers(Foreign) / 28 / Affiliate Scientist

LABELRENTALAGREEMENT: Renteragreestousethematerialsonetimeonly,forthespecifieddistributiononly,within30 daysofreceipt,andtoabidebycopyrestrictions.Rentershallnotmakeorpermitotherstomakecopiesorreproductionsofthe materialsoranydirectoryinformation inANYform,inwholeorinpart.Thisinformation cannotbestoredinelectronicmedia, computerdatabase,oranyotherform,inwholeorinpart.Allsalutationsmustbegeneralandmaynotbeindividualized.Renter agrees toprovidereasonablefacsimile ofmaterial tobedistributedandacknowledgesthatfulfillmentoforderisatthediscretion oftheACMGExecutiveDirector.I havereadandwillabideby theabove“Agreement."

Renter’sName(Pleaseprint):

Renter’sSignature: Date:

1

All ACMGMembers / 1683 / Affiliate SpecialistMembers / 67
MD FellowsUS/Canada/Foreign / 656 / Affiliate Members / 21
PhDFellowsUS/Canada/Foreign / 492 / TraineeMembers / 102
Associate Members(Counselors) / 185 / Emeritus/Honorary Members / 93
CorrespondingMembers(Foreign) / 39 / Affiliate Scientist / 28

Checkthesortorderinwhichyouwishtoreceivethem.Ifnopreference,youwillreceivefileinzipcodeorder.

Zipcodeorder Alphabetical order

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ITEM
Electronic address file 1-time use
Non-Member / $500
ACMG Member/Corporate Sponsor discount / $400
Additional for rush or order above / $150

3

OrganizationName:
Department:
Contact’s First Name: / Last Name: / Degree(s):
ACMG Member ID:
Street Address:
City: / State: / Zip: / Country (if not US):
Phone: / Fax: / Email:

CHECK

Enclosed ispayment by check. Please makecheck payable to ACMG. Checks must be payable in US Dollarsand issued by aUS CorrespondingBank. Purchaser is responsible for any and all bank charges.A $30 processing fee will be charged on all returned checks. Checks must beaccompanied by a sample of item to be posted.

CHARGE

Please chargemy: VISA MASTERCARD AMERICAN EXPRESS

This charge willappear on yourstatementas ACMG. Credit card payments maybe emailed, along with the sample to r faxed to (301) 718-9604. If you fax or email your order, please DO NOT send anoriginal form by mail.Doing somay result induplicate charges.

Credit card number: Expiration date (for example 08/08): *SecurityCode #:

Billing street address: Billing zipcode:

Name as it appears on the card:

Signature:

*Security CodeNumber:ForVISA/MasterCard-threedigitcodeonbackofcard. ForAmericanExpress-fourdigitcodeonthe front of the card. NOTE:For institutional accounting purposes, the ACMG Federal ID# is 52-1774227.

ACMG 7220 WisconsinAvenue, Suite 300 | Bethesda, MD 20814 |Phone (301) 718-9603 | Fax (301) 718-9604 | .