Becker's Hospital Review

TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com http://www.beckershospitalreview.com/annualmeeting2013.html REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. Becker's Hospital Review Annual Meeting MAY 9-11, 2013 WESTIN MICHIGAN AVENUE • CHICAGO, ILLINOIS REGISTRATION INFORMATION GENERAl INFORMATION First/Last Name: ____________________________________________________________________ CONTINuING EduCATION ACHE Degree (As you wish it to appear on your badge):______________________________________________________ Title: _______________________________________________________________________________________________ Facility/Company: __________________________________________________________________________________ Address:____________________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________ Phone: __________________________________ Fax:_____________________________________________________ Email: ______________________________________________________________________________________________ REGISTRATION FEES HOTEl RESERVATIONS ANNuAl CONFERENCE & ExHIBITS Receive multiple registrant discount(s). 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 ASC Communications is authorized to award 11.5 hours of pre-approved ACHE Qualified Education credits (non-ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credits should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification. AMOuNT FEES (Before 4/1/13) AMOuNT (After 4/1/13) 1st Attendee $675 $ _______________ $775 $ _______________ 2nd Attendee $625 $ _______________ $725 $ _______________ 3rd Attendee $575 $ _______________ $675 $ _______________ 4th Attendee or more $550 $ _______________ $650 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ _______________ PAYMENT INFORMATION K Enclosed is a check, payable to ASC Communications K I authorize to charge my: Check #: __________________ K K K Westin Hotel has set aside special group rates for conference attendees. To make a reservation, go to https://www.starwoodmeeting.com/Book/ASC2013 The Westin 909 N. Michigan Avenue, Chicago, IL 60611 (312) 943-7200 Group Room Rates: $259 CONFERENCE QuESTIONS For additional information or questions regarding the conference please contact becker@beckershealthcare.com For Becker's Hospital Review and exhibitor/ sponsorship questions contact 800-417-2035 ASC Communications, Inc. 800-417-2035 Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: __________________________________ Zip Code: ___________________________ Cardholder Billing Address: ________________________________________________________________________ City/State/Zip: ____________________________________________________________________________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ TO REGISTER COMPlETE REGISTRATION FORM ANd MAIl OR FAx AS FOllOWS: Mail: Fax: Call: Email: Web site: Make checks payable to ASC Communications Fax registration form with credit card information to 866-678-5755 Call 800-417-2035 to register by phone registration@beckershealthcare.com www.BeckersHospitalReview.com Cancellation Policy: Written cancellation requests must be received by March. 1, 2013. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. REGISTER ONlINE AT: www.beckershospital review.com/2013meeting 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 2nd location are not eligible for the discount. AdA REQuEST If you require special ADA accommodations, please contact us at 800-417-2035 ONlINE REGISTRATION www.beckershospitalreview.com/ 2013meeting Register before April 1, 2013, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 Visit www.BeckersHospitalReview.com.

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