Enrollment Form                                    
FILL-OUT, PRINT AND MAIL WITH YOUR PAYMENT to :
DEKAYE CONSULTING, INC. 231 Oakview Avenue, Oceanside, NY 11572

Company, Association, Agency or Non-submitting Facility is limited to one person only per
subscription and need only fill out questions 1-8 on enrollment form.

1. Organization/Company Name
2. Street Address
3. City State Zip
4. Primary Contact Name
5. Title
6. Phone Number
7. Fax Number
8. E-mail Address
9. Hospital Bed Size    
10. System or Individual

11. CBO (Yes or No)  
12. Secondary Contact # 1
13. Secondary Contact # 1 E-Mail
14. Secondary Contact # 2
15. Secondary Contact # 2 E-Mail

Subscription Fees

Hospital Primary Submitter  (includes 2 Secondary Contacts) [Annual 12 month period: $360.00] 
**     HOSPITAL PAMLIST MEMBERS RECEIVE $25.00 DISCOUNT [ $335.00] : MUST ENTER PAMLIST EMAIL ____________________________

Additional Access (over the 2 Secondary Contacts included) [Annual 12 month period: $50.00 each subscriber]

Company, Association, Agency or Non-submitting Facility [Annual 12 Month Period: $425.00 per subscriber]

****Tax Exempt organizations, please list tax exempt number:

Please mail your form along with check or money order to:
DEKAYE Consulting, Inc.,
231 Oakview Avenue,
 Oceanside, NY 11572
For more information call or write us at: Phone: (516) 678-2754  Fax: (516) 825-4458
Email: pfspowerrank@aol.com    www.dekaye.com