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 networking functions. MAIN CONFERENCE + PRE-CONFERENCE FEES AMOUNT FEES AMOUNT (Before 5/1/16) (After 5/1/16) 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 c Enclosed is a check, payable to ASC Communications, Inc. Check #: _______________________________________________________________________________________________ c I authorize ASC Communications, Inc. to charge my: c c c Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name:__________________________________ Zip Code:____________________________ Signature:___________________________________________________________ CVV#/3-digit #: ____________ CONTINUING EDUCATION CME Continuing Medical Education (CME) credits will be offered. Please visit our website for further details. HOTEL RESERVATIONS The Swissôtel has set aside special group rates for conference attendees. The Swissôtel 323 East Wacker Drive, Chicago, IL 60601 (312) 565-0565 Group Room Rates: $289 Single/Double Group Room Block Name: 14th Annual Spine, Orthopedic & Pain Management To make your reservation online, follow this link: www.beckersasc.com/ june-conference/hotel-travel CONFERENCE QUESTIONS For additional information regarding the conference, exhibiting or sponsoring please contact: Becker's Healthcare Phone: (800) 417-2035 Fax: (866) 678-5755 Email: registration@beckershealthcare.com ADA REQUEST If you require special ADA accommodations, please contact us at (800) 417-2035 Register before May 1, 2016, and SAVE on registration! Visit www.BeckersASC.com REGISTRATION INFORMATION First/Last Name: ______________________________________________________________________ Designation (As you wish it to appear on your badge): _________________________________________________ Title: ___________________________________________________________________________________________________ Facility/Company:______________________________________________________________________________________ Address: _______________________________________________________________________________________________ City/State/Zip: _________________________________________________________________________________________ Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax: _______________________________________________________ Email:__________________________________________________________________________________________________ 14th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine T H E 1 4 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 J U N E 9 - 1 1 , 2 0 1 6 • S W I S S 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: www.regonline.com/14thspineorthoasc 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 Online: www.regonline.comm/14thspineorthoasc Cancellation Policy: Written cancellation requests must be received within 120 days of trans- action or by May 1, 2016, whichever is first. 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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