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ALL FIELDS MUST BE COMPLETED TO BE ELIGIBLE

Name
Title
Company
Address
City
State
Zip
Phone
E-mail address
Type of Company (check all that apply) Academic Institution
Accrediting Body
Ambulatory Infusion Center
Company Headquarters
Consulting/Business Affiliate Firm
Government Agency (Federal)
Government Agency (State/Local)
HME/Respiratory
Home Health Agency
Home IV Pharmacy
Hospital
Payer
Physician’s Office
Other Pharmacy
Other
Primary Job Function (check one) Billing/Reimbursement – A/R Manager
Case Manager
Consultant
Dietitian
Discharge Planner
Educator
Financial Officer
Government
Human Resources Professional
Manager
Nurse
Operations
Owner/CEO
Pharmacist
Pharmacy Technician
Physician
Retired
Sales & Marketing Professional
Student
Technology/IT
Trustee/Board of Director
Other
What is your estimated total amount spent on purchasing supplies, products and services? (check one) $0 – 99,999
$100,000 – 249,999
$250,000 – 499,999
$500,000 – 999,999
$1 – 4.99 million
$5 - 24.99 million
$25 million and above
Not Sure
What is your organization’s total net revenue on infusion products and services? (check one) Less than $500,000
$500,000 – $999,999
$1 million – $2.99 million
$3 million – $5.99 million
$6 million – $8.99 million
$9 million – $11.99 million
$12 million – $14.99 million
$15 million – $19.99 million
$20 million – $29.99 million
$30 million – $49.99 million
$50 million – $99.99 million
$100 million – $499.99 million
$500 million & Above

Note: Above data will not be utilized externally, except in aggregate form.