Yes No
Yes, please auto-fill my contact information for other publication qualification forms.
Hospital/Nursing Home Personnel (bed count): # of Beds (Enter 'N' if unknown)
Select your Job Function President/C-level Manager VP Marketing/Sales/Operations/Business Development VP Engineering/Research/Technology Manager/Director - Marketing/Sales/Operations/Business Development Manager/Director - Engineering/Research/Technology Engineer/Researcher/Scientist Business/Sales Staff Educator Professional Services/Consultant Other (please specify) Please specify for Other:
Select Number of Employees Less than 50 50-99 100-499 500-999 1,000-4,999 5,000-9,999 Greater than 10,000
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Hospital/Nursing Home Personnel: Hospital/Nursing Home Personnel: cont. VP/Asst Adm Facilities Mgmt. Nursing Home Admin VP/Asst Adm Plant Oper/Bldgs/Grds Biomedical/Clinical Engr VP/Asst Adm Support Svcs Multi-Hospital System Personal: Dir/Asst Dir Engineering Facility Mgr/Bldgs/Mtce/etc. Dir/Asst Dir Facilities Mgmt Construction Manager Dir/Asst Dir Plant Oper/Bldgs In-House Architect Dir/Asst Dir Support Services Other Health Care Organization Personnel: Dir/Asst Dir/Chief of Maintenance Medical Clinic/Group Practice Dir/Asst Dir Env Svcs/Hskpg Surgi/Emerg/Ambul Ctr Dir/Asst Dir Safety/Security Architectural Firm Dir Planning/Development Consultant Firm Matls Mgr/Chief Purch Ofcr Building Contractor Infection Control Officer Govt/Vol Health Org Construction Manager Group Purchasing Org Laundry Manager Interior Designer In-House Architect Landscaping Professional Dir/Asst Dir Telecommun Mfg Equip & Svcs Data Processing Manager Other (please specify)
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Which of the following best describes your industry? (select only one) Arts & Entertainment Home & Garden Automotive Industry & Agriculture Business & Professional Services Legal & Finance Clothing & Accessories Media & Communications Community & Government Personal Care & Services Computers & Technology Real Estate Electronics Retail Food & Beverage Sports & Recreation Food & Dining Travel & Transportation Health & Medicine Other
Arts & Entertainment Home & Garden Automotive Industry & Agriculture Business & Professional Services Legal & Finance Clothing & Accessories Media & Communications Community & Government Personal Care & Services Computers & Technology Real Estate Electronics Retail Food & Beverage Sports & Recreation Food & Dining Travel & Transportation Health & Medicine Other
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What is the number of employees in your entire organization? (select only one) 1-99 1,000-4,999 100-999 5,000+ Do you currently have a budget defined for your project? Yes No If Yes, are you the budget owner? Yes No How many months have you been researching potential solutions? (select only one) 0-3 months 6-9 months 3-6 months 9-12 months What is your timeframe for making a purchasing decision? (select only one) 90 days or less 181 days to 270 days 91 to 180 days 271 days to 360 days
1-99 1,000-4,999 100-999 5,000+
Yes No If Yes, are you the budget owner? Yes No
0-3 months 6-9 months 3-6 months 9-12 months
90 days or less 181 days to 270 days 91 to 180 days 271 days to 360 days
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