Yes     No

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

Yes, please auto-fill my contact information for other publication qualification forms.

Chain ASC	Surgical Hospital
Independent ASC	Consultant
Hospital/ Outpatient Facility	Private Practice/ Group Medical/ Specialty Boutique
Group Purchasing Organization	Supplier
Hospital	Other (please specify)

Corporate Management	Administrators cont.
CEO	Manager
COO	CASC
CFO	Materials Manager
CIO	Director of Purchasing
Board Member	Director of Nursing
Principal	Other Administrator (please specify)
President
Vice President	Physician
Other Corporate Management (please specify)	Surgeon
	Director of Surgery
Operating Room Management	Chief of Staff
O.R. Director	Medical Director
O.R. Manager	Other Physician (please specify)
Director of Surgical Services
Other O.R. Management (please specify)	Others Allied to the Field
	Consultant
Administrators	Anesthesiologist
Administrator	Staff Nurse
Director	Other

Yes	No	Capital Equipment
Yes	No	Surgical Supplies
Yes	No	Pharmaceuticals
Yes	No	Business Supplies & Services
Yes	No	Financial Services, Consultants, Contractors

Yes     No

Single Specialty     Multi Specialty

Yes     No

1     2 to 3     4 or more

Yes     No

Yes     No

Yes     No

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