Thank you for your interest in joining the Clinical Executive Roundtable. Please complete the form below in its entirety & someone will be in touch with you regarding your no fee membership with 2-3 business days.

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* 1. Full Name

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* 3. Cell Phone

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* 4. Job Title

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* 5. Company/Organization

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* 6. Number of facilities your company operates

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* 7. States in which your company operates

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* 8. How did you hear about the Clinical Executive Roundtable?

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* 9. If you were referred by a Member or Colleague please list their name here so we can thank them & acknowledge their contribution:

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* 10. What are the top 2-3 clinical or operational challenges you’d like to explore with peers?

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