Becker's Spine Review

RegISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. 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 AMOuNT FeeS AMOuNT (Before 5/1/14) (After 5/1/14) 1st Attendee $800 $ _______________ $900 $ _______________ 2nd Attendee $775 $ _______________ $875 $ _______________ 3rd Attendee or more $750 $ _______________ $850 $ _______________ 4th Attendee or more $725 $ _______________ $825 $ _______________ Add $100 to subscribe to Becker's ASC Review (+$100) $ _______________ or Becker's Spine Review ToTal EnclosEd $ ______________ PAYMeNT INFORMATION q Enclosed is a check, payable to ASC Communications, Inc. Check #: ______________ q I authorize ASC Communications, Inc. to charge my: q q q Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: __________________________________ Zip Code: ___________________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ CONTINuINg eDuCATION ACHE ASC Communications is authorized to award 14.5 hours of pre-approved ACHE Qualified Education credits (non- ACHE) for this program toward advancement, or recerti- fication in the American College of Healthcare Executives. Participants in this program wishing to have the continu- ing 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 activi- ty for a maximum of 13 AMA PRA Category 1 Credits TM . 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 Credits TM 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/orthoasc14 The Westin 909 N. Michigan Avenue, Chicago, IL 60611 (312) 943-7200 Group Room Rates: $299 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 Register before May 1, 2014, and SAVe on registration! For information on exhibiting and sponsorships, call (800) 417-2035 Visit www.BeckersASC.com. 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 12th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine t h e 1 2 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 a t i o n s JUNE 12-14, 2014 • wEstiN HotEl • CHiCago, illiNois to register, call (800) 417-2035 RegISTeR ONlINe AT: http://www.regonline.com/12thspineorthopedicASC 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 Cancellation Policy: Written cancellation requests must be received by May 1, 2014. 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 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.

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