Facility member application form

MUSE is always a wealth of information and a great opportunity to network. - Judy Kurtz of Good Shepherd Medical Center, OR

Application date: Feb 3 2012

Facility name: *

Facility address

Address: *

City: *

Province/state: *

Alternate province/state:

Postal/zip code: *

Country: *

Phone:

Ext:

Fax:

Website:

Primary contact

Name: *

Job title: *

Email: *

Position type: *

Alternate position type:

Position level: *

Alternate position level:

Role in purchasing products/services: *

I use or am responsible for these MEDITECH modules: *

You can select up to 7 modules

Facility details

The hospital uses the following MEDITECH platform(s): *

6.0

Magic

Client/Server

Not applicaple

Select up to 2 platform options

Membership level (# of Acute Care Beds): *

Number of MEDITECH modules:

Number of hospitals: *

Number of acute beds:

Number of other beds:

Number of employees:

Number of IS employees:

How did you hear about MUSE?:

CIO contact info

Name:

City:

Province/state:

Alternate province/state:

Postal/zip code:

Country:

Phone:

Ext:

Email:

CFO contact info

Name:

City:

Province/state:

Alternate province/state:

Postal/zip code:

Country:

Phone:

Ext:

Email: