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. REGISTRATION FEES FEES AMOUNT FEES AMOUNT (Before 9/1/16) (After 9/1/16) 1st Attendee $700 $ _______________ $800 $ _______________ 2nd Attendee $650 $ _______________ $750 $ _______________ 3rd Attendee $625 $ _______________ $725 $ _______________ 4th Attendee or more $600 $ _______________ $700 $ _______________ (Ask about larger group discounts) TOTAL ENCLOSED $ ______________ PAYMENT INFORMATION q Enclosed is a check, payable to ASC Communications Check #: __________________ q I authorize ASC Communications to charge my: q q q Credit Card Number: _______________________________________ Expiration Date: _____________________ Printed Cardholder Name: _________________________________________________________________________ Billing Address:____________________________________________________________________________________ City: _______________________________________________________ State: ____________ Zip ________________ Signature: __________________________________________________________ CVV#/3-digit #: _____________ CONTINUING EDUCATION CME and AEU Credit will be offered. More details to come. HOTEL RESERVATIONS Swissôtel has set aside special group rates for conference attendees. To make a reservation, go to https://resweb.passkey.com/go/23rdasc Swissôtel 323 E. Wacker Drive, Chicago, IL 60601 Phone 1-888-737-9477 • Fax 1-312-565-0540 Group name: Annual ASC Conference Group Rate: $289 Single/Double 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 ASC 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 (703) 836-5904 ONLINE REGISTRATION https://www.regonline.com/23rdAnnualASC Register before September 1, 2016, and SAVE on registration! For information on exhibiting and sponsorships, call (800) 417-2035 125 Speakers from Surgery Centers, 54 Surgeons Speaking, 61 ASC Administrators Speaking, 206 Total Speakers • Keynote Speakers Pat Riley, Sugar Ray Leonard and Lee Woodruff • Register by Sept. 1st for Early Registration Discounts! 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Becker's ASC 23rd Annual Meeting - The Business and Operations of ASCs F R O M B E C K E R ' S A S C R E V I E W , A S C C O M M U N I C A T I O N S OCTOBER 27-29, 2016 S W I S S Ô T E L • C H I C A G O , I L L I N O I S To Register, Call 800-417-2035 • Fax 866-678-5755 • Email: registration@beckershealthcare.com REGISTER ONLINE AT: https://www.regonline. com/23rdAnnualASC TO REGISTER COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Mail: Make checks payable to ASC Communications, Inc. and mail to: ASC Communications, Inc., 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 within 120 days of transaction or by Sept 1st, 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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