Conference Materials

REGISTRATION FORM Photocopies are acceptable. Please print or type below. Please use a separate registration form for each attendee. HOTEL RESERVATIONS The Swissotel Chicago 323 East Wacker Drive Chicago, IL 60601 Phone: (888) 737-9477 Group Name: Becker's CEO Roundtable Group Rate: $309 Single/Double https://resweb.passkey.com/go/beckersceo 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 ADA REQUEST If you require special ADA accommodations, please contact us at 800-417-2035 ONLINE REGISTRATION www.regonline.com/ceoroundtable2016 Register before October 1, 2016, and SAVE on registration! For information on exhibiting and sponsorships, call 800-417-2035 GENERAL INFORMATION TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com https://www.regonline.com/ceoroundtable2016 TO REGISTER COMPLETE REGISTRATION FORM AND MAIL OR FAX AS FOLLOWS: Online: https://www.regonline.com/ceoroundtable2016 Mail: Make checks payable to ASC Communications and mail to: 315 Vernon Ave. 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 Cancellation Policy: Written cancellation requests must be received within 120 days of transaction or by Sept. 1, 2016, whichever is first. Refunds are subject to a $100 processing fee. Refunds will not be made after this date. Becker's Hospital Review 5 th Annual CEO + CFO Roundtable November 7-9, 2016 • Chicago REGISTRATION FEES CEO + CFO ROUNDTABLE & 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. FEES AMOUNT FEES AMOUNT (Before 10/1/16) (After 10/1/16) 1st Attendee $800 $ ____________________ $900 $ ___________________ 2nd Attendee $750 $ ____________________ $850 $ ___________________ 3rd Attendee or more $700 $ ____________________ $800 $ ___________________ (Ask about larger group discounts) TOTAL ENCLOSED $ ______________ PAYMENT INFORMATION c Enclosed is a check, payable to ASC Communications Check #: _______________________ c I authorize to charge my: c c c 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ To register online visit: https://www.regonline.com/ceoroundtable2016

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