Conference Materials

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 5/1/15) (After 5/1/15) 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 CME CME credit will be offered. Further details to be provided shortly. HOTEL RESERVATIONS Westin Hotel has set aside special group rates for conference attendees. The Westin 909 N. Michigan Avenue, Chicago, IL 60611 (312) 943-7200 Group Room Rates: $309 Group Room Block Name: Annual Spine Conference 2015 To make your reservation online, follow this link: https://www.starwoodmeeting.com/Book/asc15 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 accommoda- tions, please contact us at (800) 417-2035 ONLINE REGISTRATION http://www.beckersasc.com/Junereg2015 Register before May 1, 2015, 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 13th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine T H E 1 3 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 11-13, 2015 • 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 TO REGISTER, CALL (800) 417-2035 REGISTER ONLINE AT: http://www.beckersasc.com/Junereg2015 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, 2015. 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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