Compli Cancellation Request

Compli Cancellation Request Form

Name(Required)

First Last

Email(Required)

Practice Name(Required)

Practice Address(Required)

Street Address Address Line 2 City State ZIP Code

Are you a DSO/MSO or have more than 1 office/locations?(Required)

Name of DSO/MSO or Office's Regional Manager

Number of locations

Name of Distributor and/or Sales Rep (if any)

Reason for cancellation:(Required)

How do you plan to handle your practice(s)' compliance with OSHA/IC/HIPAA moving forward without Compli?(Required)

Date of cancellation(Required)

Date subscription started(Required)

When was the last time the platform has been utilized for training, logging, etc.?(Required)

Are there any functions/features of the platform that you would like to have that you do not see currently?(Required)