Conference Materials

REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. HOTEL RESERVATIONS Hotel Room Block Information Coming Soon! Ritz Carlton Chicago 160 E. Pearson St. • Chicago, IL (312) 266-1000 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 For Becker's Hospital Review and exhibitor/ sponsorship questions contact 800-417-2035 ASC Communications, Inc. 800-417-2035 ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION https://www.regonline.com/ ceoroundtable2015 Register before October 1, 2015, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 For more information about Becker's Hospital Review Visit www. beckershospitalreview.com or call us at (800) 417-2035 GENERAL INFORMATION Visit www.BeckersHospitalReview.com TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com https://www.regonline.com/ceoroundtable2015 REGISTER ONLINE AT: https://www.regonline. com/ceoroundtable2015 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. TO REGISTER COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Mail: Make checks payable to ASC Communications 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.BeckersHospitalReview.com Cancellation Policy: Written cancellation requests must be received by Sept. 1, 2015. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Becker's Hospital Review 4th Annual CEO Roundtable + CFO/CIO Roundtable November 18-19 • Chicago 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 FEES AMOUNT FEES AMOUNT (Before 10/1/15) (After 10/1/15) 1st Attendee $800 $ _______________ $900 $ _______________ 2nd Attendee $750 $ _______________ $850 $ _______________ 3rd Attendee or more $700 $ _______________ $800 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ _______________ PAYMENT INFORMATION q Enclosed is a check, payable to ASC Communications Check #: __________________ q I authorize to charge my: q q q Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: __________________________________ Zip Code: ___________________________ Cardholder Billing Address: ________________________________________________________________________ City/State/Zip: ____________________________________________________________________________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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