How Did You Hear About Us? --Choose One-- Direct Mail (postcard, newsletter, etc.) Google Ad in publication Email notice Trade show Search engine Previous use Referral Other *First Name: *Last Name: *Department: *Organization: *Address: *City: *State: *Zip: *Phone: Ext: Fax: *Email: # of beds: # of Employees: Facility's corporation:  My request for software: --Choose One-- Has been approved Is pending approval in this budget year Will be submitted in the next budget Other Budget Year: Select a date to attend a free web demo at 10 AM Central Time: AICE — Infection Control Software Respond — Employee Health Software May 08 , 2008 May 22, 2008 Jun 12, 2008 Jun 26, 2008 Jul 10, 2008 Jul 24 , 2008 Aug 19, 2008 Aug 28, 2008 Sep 11, 2008 Sep 25, 2008 Oct 09, 2008 Oct 23, 2008 Nov 06, 2008 Nov 20, 2008 Dec 04, 2008 Dec 18, 2008     RedBat — Syndromic Surveillance   May 15, 2008 Jul 17, 2008 Aug 21, 2008 Sep 18, 2008 Oct 16, 2008 Nov 13, 2008 Dec 11, 2008   Comments:   * are required fields

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ICPA, Inc.
515 South Capital of
Texas Highway,
Suite 240
Austin, TX 78746-4305
(800) 426-8015
ext. 224
sales@icpa.net