Becker's Spine Review

to register, call (800) 417-2035 RegISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. 11th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference Improving Profitability and Business and Legal Issues t h e 1 1 t h a n n u a l c o n f e r e n c e f r o m a s c c o m m u n i c at i o n s JunE 13-15, 2013 WESTIN HOTEL • CHICAGO, ILLINOIS geNeRAl INFORMATION RegISTRATION INFORMATION First/Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Degree (As you wish it to appear on your badge): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Facility/Company: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City/State/Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ RegISTRATION FeeS 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 1st Attendee 2nd Attendee 3rd Attendee FeeS (Before 5/1/13) $625 $575 $525 4th Attendee or more $500 (Ask about larger group discounts) AMOuNT $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ FeeS (After 5/1/13) $725 $675 $625 AMOuNT $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $600 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ FeeS AMOuNT hOTel ReSeRVATIONS Westin Hotel has set aside special group rates for conference attendees. To make a reservation, go to http://www.starwoodmeeting.com/ Book/ascjune2013 The Westin 909 N. Michigan Avenue Chicago, IL 60611 (312) 943-7200 Group Room Rates: $289 CONFeReNCe QueSTIONS For additional information or questions regarding the conference please contact ASC Communications Phone: (800) 417-2035 Fax: (866) 678-5755 email: registration@beckershealthcare.com MAIN CONFeReNCe + PRe-CONFeReNCe FeeS 1st Attendee 2nd Attendee (Before 5/1/13) $725 $675 3rd Attendee or more 4th Attendee or more $625 $600 AMOuNT $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (After 5/1/13) $825 $775 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $725 $700 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (+$100) $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Add $100 to subscribe to Becker's ASC Review or Becker's Orthopedic & Spine Review For Becker's ASC Review and exhibitor/ sponsorship questions contact (800) 417-2035 ADA ReQueST If you require special ADA accommodations, please contact us at (800) 417-2035 ToTal EnclosEd $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PAYMeNT INFORMATION q Enclosed is a check, payable to ASC Communications, Inc. q I authorize ASC Communications, Inc. to charge my: q ONlINe RegISTRATION Check #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ q http://www.regonline.com/ 11thorthopedicspineASC q Credit Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Printed Cardholder Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Zip Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CVV#/3-digit #: _ _ _ _ _ _ _ _ _ _ _ _ _ TO RegISTeR COMPleTe RegISTRATION FORM AND MAIl OR FAx AS FOllOWS: Make checks payable to ASC Communications and mail to: ASC Communications June Meeting, 315 Vernon Avenue, Glencoe, IL 60022 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 Web site: www.BeckersASC.com Mail: Cancellation Policy: Written cancellation requests must be received by May 1, 2013. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. RegISTeR ONlINe AT: http://www.regonline.com/ 11thorthopedicspineASC Multi-Attendee Discount Policy: To be eligible for the discount, your ASC 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. Register before May 1, 2013, and SAVe on registration! For information on exhibiting and sponsorships, call (800) 417-2035 Visit www.BeckersASC.com.

• Cover