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First Name:
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M.I.:
Last Name:
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Email Address:
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Verify Email Address:
Role:
Hospital Administrator (including CEO / CFO)
Nurse
Pharmacist
Pharmacy Director
Physician
Physician Assistant
Practice Manager
Other:
ME Number:
Primary Workplace Setting:
Private Clinic
Public Clinic
Community Hospital
Academic Hospital
VA Hospital
Retail Pharmacy
Industry
Gender:
Male
Female
Year Of Birth:
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Year Started Practice:
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Title:
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Company/Practice Name:
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Department:
Business Address:
Street:
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City:
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State:
Alabama
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
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Vermont
Virginia
Washington
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Wisconsin
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Other
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Zip Code:
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Country
United States of America
Afghanistan
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Antarctica
Antigua and Barbuda
Argentina
Armenia
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Australia
Austria
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Bahamas
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Bangladesh
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Belgium
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Benin
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Bhutan
Bolivia
Bosnia Hercegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
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Bulgaria
Burkina Faso
Burundi
Byelorussian SSR
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Czechoslovakia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Islamic Republic of Iran
Israel
Italy
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Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
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Latvia
Lebanon
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Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
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Monaco
Mongolia
Montserrat
Morocco
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Myanmar
Namibia
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Nepal
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Netherlands Antilles
Neutral Zone
New Caledonia
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Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of Moldova
Republic of Yemen
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent & Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Soviet Union
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukrainian SSR
United Arab Emirates
United Kingdom
United Republic of Tanzania
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yugoslavia
Zaire
Zambia
Zimbabwe
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Phone No:
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Fax No:
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Which of the following best describes your primary workplace setting:
Hospital: in-patient
Hospital: out-patient
Hospital: pharmacy
Hospital: other
Physician office: private
Physician office: hospital affiliated
Retail pharmacy
Academic medical center
*
Are you board certified?
Yes
No
If you are not board certified, what are your primary and secondary specialties?
In what specialty are you board certified?
Allergy & Immunology
Anesthesiology
Colon & Rectal Surgery
Dermatology
Emergency Medicine
Family Medicine
Internal Medicine
Medical Genetics
Neurological Surgery
Obstetrics & Gynecology
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Physical Med & Rehabilitation
Plastic Surgery
Preventative Medicine
Psychiatry & Neurology
Radiology
Surgery
Thoracic Surgery
Urology
*
In what subspecialty are you certified?
*
In what tertiary specialty are you certified?
*
Do you perform Clinical Trials?
frequently involved
rarely involved
never involved
*
Honorarium Address:
(Provide only if different from above address.)
Street:
City:
State:
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
Other
Zip Code:
Country:
United States of America
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Hercegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Byelorussian SSR
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Czechoslovakia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Islamic Republic of Iran
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of Moldova
Republic of Yemen
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent & Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Soviet Union
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Is.
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukrainian SSR
United Arab Emirates
United Kingdom
United Republic of Tanzania
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yugoslavia
Zaire
Zambia
Zimbabwe
Disclaimer:
The registrant understands that by completing this form, he / she will be added to the ICI contact list making him / her eligible to receive invitations via email, fax or phone to participate in market research studies. If at any time the participant ever wants to be removed from the ICI contact list, then he / she may select the "Opt-Out" option available at the bottom of each invitation, or can submit a request in writing to the following email address:
ici@icimrr.com
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