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I Am:
For companies with multiple Compliance Officers, please list areas of responsibility:
Prefix
Mr. Ms. Mrs. Miss Dr. The Honorable
*First Name
MI
*Last Name
Suffix
*Company:
Title:
*E-mail Address:
*E-mail Address:(re-enter for verification)
*Line 1:
Line 2:
*City:
*State:
*Zip Code:
Country:
Business Phone:
Business Fax:
The compliance officer is external legal counsel.
A. To be completed if you are the compliance officer named above.
In addition to my name, title and company Web address, please post the following contact information to be posted on AdvaMed.org:
Preferred Web address:
Phone:
Fax:
*Completing this section authorizes AdvaMed to make your e-mail address publicly available and, therefore, potentially captured by spammers. Personal e-mail addresses are not recommended; alternate addresses may be preferred.
Email:
To be completed only if you an AdvaMed Special Representative nominating a Compliance Officer.
I have notified the compliance officer that this information will be provided on the Web.
Nominating Representative Contact Information
Name:
E-mail:
Comments:
