Thank you for playing the LodgeNetRX Scratch & Win game. Submit your information below, then enter your pin code to find out if you have won $25,000 for your hospital foundation.

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*First Name:    *Last Name:
*Title:
*E-mail Address:
*Phone Number (work):
*Fax Number (work):

*Healthcare Facility Name:
*Healthcare Facility Address:
*City:    *State:    *Zip:
*Country:

*Number Of Beds At Your Facility:
 
*Are you a member of a GPO:
  If Yes, *name of GPO:
 
  *Are you a member of a Health System
  If Yes, *name of Health System:
 
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