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Associate Membership Form

Facility:
Address:
City:
State/Province
Country
Zip/Postal Code:
Website:
Name:    Title:
Phone:    Email:

Facility Profile:
Configuration?
Facility platform:   Magic   Client/Server   Both Magic and C/S
Approximate number of MEDITECH modules contracted:
Size?
If this membership is for a Health Region, Partnership, or Corporation, how many acute care hospitals are covered by this membership:   
Approximate number of acute care beds:   
Approximate number of 'other' beds:
(i.e. Rehab; Psych; Long Term Care; Extended Care; etc)		   
Approximate number of employees:   
Approximate number of IS employees:   
How did you hear about MUSE? (MUSE offers incentives to those who assist with the recruiting of new members):


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