Conference Materials

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. 12th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Business of Spine t h e 1 2 t h a n n u a l c o n f ere n c e f r o m as c c o mm u n i c at i o n s JUNE 12-14, 2014 • w e s t i n H o t e l • C h i c a g o , I l l i n o i s 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 and 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 + Pre-ConferencE Fees AmountFees 1st Attendee 2nd Attendee 3rd Attendee or more (Before 5/1/14) $800 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $775 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $750 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4th Attendee or more $725 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Add $100 to subscribe to Becker's ASC Review or Becker's Spine Review Payment information q Enclosed is a check, payable to ASC Communications, Inc. q I authorize ASC Communications, Inc. to charge my: q Amount (After 5/1/14) $900 $875 $850 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $825 $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (+$100) $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Total Enclosed$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Check #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ q 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: Mail: 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 C ancellation 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: CONTINUING EDUCATION ACHE ASC Communications is authorized to award 14.5 hours of pre-approved ACHE Qualified Education credits (nonACHE) 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. CME This CME activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the Joint Sponsorship of the Institute for Medical Studies (IMS) and ASC Communications. The Institute for Medical Studies designates this live activity for a maximum of 14.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses may claim credit for activities approved for AMA PRA Category 1 CreditsTM in most states, for up to 50% of the nursing requirement for recertification. Please check with your own state association for more information. HOTEL RESERVATIONS Westin Hotel has set aside special group rates for conference attendees. To make a reservation, copy and paste this link into your web browser https://www.starwoodmeeting.com/Book/ASCJune 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 Becker's Healthcare Phone: (800) 417-2035 Fax: (866) 678-5755 Email: registration@beckershealthcare.com 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 ONLINE REGISTRATION http://www.regonline.com/12thspineorthopedicASC http://www.regonline.com/12thspineorthopedicASC Register before May 1, 2014, and SAVE on registration! 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. For information on exhibiting and sponsorships, call (800) 417-2035 Visit www.BeckersASC.com.

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