Conference Materials

REGISTRATION INFORMATION REGISTRATION FEES REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. CONTINUING EDUCATION This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of The Institute for Medical Studies and Becker's Healthcare. The Institute for Medical Studies is accredited by the ACCME to provide continuing medical education for physicians. The Institute for Medical Studies designates this live activity for a maximum of 13.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This program is approved for 11.00 hours of AEU credits by BASC Provider #3672 For information on additional credits offered please visit our website. www.beckersasc.com/ annual-ambulatory-surgerycenters-conference/ credits.html. HOTEL RESERVATIONS The Swissotel Chicago has set aside special group rates for conference attendees. To make a reservation, please visit: https://aws.passkey.com/go/24aac Swissotel Chicago 323 E. Upper Wacker Drive Chicago, IL 60601 312 565 0565 CONFERENCE QUESTIONS For additional information regarding the conference, exhibiting or sponsoring please contact: Becker's Healthcare Phone: 800 417 2035 Fax: 866 678 5755 Email: registration@beckershealthcare.com ADA REQUEST If you require special ADA accommodations, please contact us at 800 417 2035. ONLINE REGISTRATION www.beckersasc.com/annual- ambulatory-surgery-centers-conference/ 137 LEADERS SPEAKERS DIRECTLY FROM SURGERY CENTERS 190+ SPEAKERS TOTAL TO REGISTER: CALL 800 417 2035 • FAX 866 678 5755 • REGISTRATION@BECKERSHEALTHCARE.COM OR VISIT www.beckersasc.com/annual-ambulatory-surgery-centers-conference/ COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Online: https://www.regonline.com/Register/Checkin.aspx?EventID=1865011 Fax: Fax registration form with credit card information to 866-678-5755 Call: Call 800-417-2035 to register by phone Email: registration@beckershealthcare.com Cancellation Policy: Written cancellation requests must be received within 120 days of transaction or by Sept. 1, 2017, whichever is first. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Multi-Attendee Discount Policy: To be eligible for the discount, your hospital must be registered at one time and work at the same address. Just copy the registration form for each attendee. Employees from a second location are not eligible for the discount. Becker's ASC Review Annual Meeting OCTOBER 26-28, 2017 | SWISSOTEL | CHICAGO, ILLINOIS ANNUAL CONFERENCE & EXHIBITS – One reasonable registration price - come for as much of the conference as you would like! Receive multiple registrant discounts. The more people you send, the greater discount you receive. The prices listed below are per person. Your registration includes all conference sessions, materials and the meal functions. MAIN CONFERENCE ONLY FEES AMOUNT FEES AMOUNT (Before 9/1/17) (After 9/1/17) 1st Attendee $850 $ __________________ $950 $ _______________ 2nd Attendee $825 $ __________________ $925 $ _______________ 3rd Attendee $800 $ __________________ $900 $ _______________ 4th Attendee or more $775 $ __________________________ $875 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $________________________________ c I authorize to charge my: c c c Credit Card Number: __________________________________ Expiration Date: _____________________ Printed Cardholder Name: _____________________________ Zip Code: ___________________________ Cardholder Billing Address: ___________________________ City/State/Zip:_______________________ Signature: ______________________________________________ CVV#/3-digit #:______________________ First/Last Name: ________________________________________________________________________________________ Degree (As you wish it to appear on your badge): _____________________________________________________ Title: ___________________________________________________________________________________________________ Facility/Company: _____________________________________________________________________________________ Address: _______________________________________________________________________________________________ City/State/Zip: _________________________________________________________________________________________ Phone:__________________________________ Fax: ________________________________________________________ Email:__________________________________________________________________________________________________ GENERAL INFORMATION TO REGISTER PAYMENT INFORMATION www.BeckersASC.com

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