Complete and verifiable information is required in order to qualify for this Magazine Subscription.

First Name: Last Name:   Job Title:   Company Name:   Business Email: Phone: Fax:

Division/Mail Stop: Street Address: City: State/Province: Select for USA, Canada, or Mexico Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Marshall Islands Micronesia (Federated States of) Palau Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands Northern Mariana Islands Armed Forces Americas AA Armed Forces Middle East, Europe, Canada AE Armed Forces Pacific AP Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Chihuahua Distrito Federal Durango Guanajuato Guerrero Hidalgo Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Queretaro Quintana Roo San Luis Potosi Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz Yucatan Zacatecas Other Postal/ZIP Code: Country: Select Country UNITED STATES CANADA INDIA UNITED KINGDOM == AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN AZORES BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BR VIRGIN ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANARY ISLANDS CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REP CHAD CHANNEL ISLANDS CHILE CHINA, PEO REPBL CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ELAND ISLANDS EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUINEA FRENCH POLYNESIA GABON, REPUBLIC OF GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA BIASSAU GUINEA,REPUBLIC OF GUYANA HAITI HONDURAS HONG KONG HUNGARY ICELAND INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KOREA,DEMOCRATIC REPUBLIC OF KOREA,REPUBLIC OF KOSOVO KUWAIT KYRGZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MADEIRA MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU ISLANDS NEPAL NETHERLANDS ANTILLES NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL QATAR REPUBLIC OF KIRIBATI REUNION ROMANIA RUSSIAN FED RWANDA SAINT PIERRE AND MIQUELON SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOCIETY ISLANDS SOLOMON ISLANDS SOMALIA,REPUBLIC SOUTH AFRICA SPAIN SRI LANKA ST KITTS ST LUCIA ST VINCENT SUDAN SURINAM SWAZILAND SWEDEN SWITZERLAND SYRIA TAHITI TAIWAN TAJIKISTAN TANZANIA THAILAND TIMOR-LESTE TOGO TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNION OF MYANMAR UNITED ARAB EMIRATE UNITED KINGDOM,ENGLAND UNITED KINGDOM,NO.IRELAND UNITED KINGDOM,SCOTLAND UNITED KINGDOM,WALES URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM, RPBLC OF VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA WESTERN SAMOA YEMEN ZAMBIA ZANZIBAR ZIMBABWE OTHER

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

Your offer confirmation will be sent to your business email address entered above.

	Yes, I would like to receive Healthcare Purchasing News' daily email newsletter.
	Yes, send me special offers, contests, etc, via email.
	(Please note that Healthcare Purchasing News will NOT release your email address to any other company or individual.)

What is the approximate number of employees in your company?

Select Number of Employees 50,000+ 20,000 - 49,999 10,000 - 19,999 5,000 - 9,999 2,500 - 4,999 1,000 - 2,499 500 - 999 250 - 499 100 - 249 50 - 99 25 - 49 10 - 24 5 - 9 1 - 4

---

1.

Do you wish to receive a FREE subscription to Healthcare Purchasing News?

Yes     No

2.

The name of the high school you graduated from: (This question is asked only as a replacement for your signature to verify the subscription for auditing purposes)

3.

Are you a member of a product evaluation committee?

Yes     No

4.

Please indicate type of Facility/Service/Firm:

Select type of Facility/Service/Firm Stand Alone Hospital (for-profit, non-profit, government) Integrated Network (multiple hospitals and alternate sites) Hospital Group Purchasing Organization or Alliance Multi-Hospital System Corporate Headquarters Government Purchasing Agencies Surgi-Center/Ambulatory Care Center Long-Term Care Home Health Care HMO/PPO Insurance/Accounting/Investment/3rd Party Administrator Distributor Manufacturer Other

Please Specify for Other:

5.

Please select the category that best describes your job title:

Select job title VP/Director/Manager of Material Asst Material Mgr/Other Material Mgmt Personnel Chief Purchasing Director/Purchasing Manager Buyer/Purchasing Agent/Other Purchasing Personnel Central Service Director/Supervisor/Manager Other Central Service Personnel (Tech, Coord) Infection Control Practitioners/Director/Supervisor OR Director/Manager/Supervisor Surgical Services Director/Manager/Supervisor OR Material Manager Other OR Personnel involved in Purchasing VP Support Services Hospital Administrator CEO, CFO, COO Head Nurse/Director of Nursing Medical Director Nursing/Practitioner Consultant Value Analysis Coordinator Professional Department Head Evaluation/Standardization & Safety Committee Member Contracts Director/Manager/Supervisor Clinical Educator Other

Please Specify for Other:

6.

Number of beds in your organization?

Select number of beds 500+ 400-499 300-399 200-299 100-199 50-99 26-49 0-25

7.

Please check the area for which you have purchasing involvement:

Select purchasing involvement Operating Room Products & Equipment Infection Control Products & Equipment Business Equipment & Supplies Central Service Products & Equipment Monitoring & Diagnostic Equipment

8.	Which of the following products/services do you recommend, specify, or buy? (select all that apply)

	INVENTORY CONTROL	OPERATING ROOM cont.
	Asset Management Products/Services	Gowns and Protective Wear
	Bar Coding/RFID, RTLS & Labeling Systems	Instruments
	Cabinets	Orthopedics
	Carts	Scheduling Systems
	Computer Hardware	Surgical Gloves
	Contract Management Systems	Surgical Lights, Lighting Systems
	File & Retrieval Systems	Tables and Stretchers
	Forms	Wound Care/Hypothermia Products
	Handheld/Point-of-Use Products	Other OR Products
	Instrument Tracking Systems	INFECTION CONTROL
	Materials Management/Supply Chain Info Systems incl. ERP modules	Air Purification Systems
	Printers/Scanners/Copiers/Multi-function	Cleaning Equipment & Supplies
	Storage Systems	Disaster Preparedness Products
	Other Inventory Control Products	Disinfectants & Sterilants
	PATIENT CARE	E†O Monitoring Devices
	Bariatric Specialty Equipment/Supplies	Gloves
	Diagnostic Equipment	Hand Hygiene Products & Dispensers
	ID/Security/Alert Systems	Protective Wear
	IV Systems/Syringes	Sharps Safety Products
	Linen	Sterilization Supplies & Equipment
	Patient Beds/Furniture	Sterilization Wraps & Containers
	Patient Transport/Lift Products	Other Infection Control Products
	Patient Warming/Positioning Products	OTHER PURCHASING & SERVICES
	Respiratory Care & Monitoring	Business Equipment & Supplies
	Scales	Communications Equipment
	Temperature/Blood Pressure Monitors	Environmental Services Products
	Wound Management/Bandages/Wraps	Facility Equipment & Maintenance
	Other Patient Care Products Equipment	Food & Dietary Supplements
	OPERATING ROOM	Food Service Equipment
	Cardiac Equipment and Supplies	Imaging Supplies & Equipment
	Catheters/Needles	Laundry Supplies & Equipment
	Critical Care	Shipping and Transportation
	Custom Procedure Trays/Kits/Packs	Waste Management
	Drapes	None of the Above
	Endoscopy/Endoscopic Products

---

Would you like to receive EMAIL notices of other print or online publications, and other relevant offers from TradePub.com?

Yes     No

Sign up for special offer alerts from select partners featuring the latest products and services you are interested in.

Yes     No