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Registration Form

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Personal Information

Fill out the information below, then click Next to continue.

First Name

Last Name

CredentialsOther

Email address

Company name

Specialty

Address

Address 1

Address 2

City

State/Province

ZIP/Postal Code

Country/Region

Mobile

Your Profession

Pharmacist

Physician

Nurse

Other

Place of EmploymentOther

Bed size (select one):

Are you a member of your site's P&T Committee?

Yes

Not Applicable

Are you a member of your practice site's Antimicrobial Stewardship Committee?

Yes

Not Applicable

If you are a pharmacist, do you have prescribing privileges?

Yes

Not Applicable

Are you involved in any collaborative practice arrangements?

Yes

Do you have direct influence on patient-specific antimicrobial therapy in your practice site?

Yes

If you are paying with a credit card that has a different name than the person registering, please list the name as it appears on the credit card here:

Packages

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Payment Section

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Package Name

Package Expiry Priority

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