Register online here: https://www.regonline.com/ceoroundtable2016
REGISTRATION INFORMATION
REGISTRATION FEES
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
TO REGISTER, CALL 800-417-2035 • FAX 866-678-5755 OR EMAIL: registration@beckershealthcare.com
https://www.regonline.com/ceoroundtable2016
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
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 $_____________
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 #:____________________
First/Last Name: __________________________________________________________________________
Degree (As you wish it to appear on your badge): _________________________________________
Title: _____________________________________________________________________________________
Facility/Company: ________________________________________________________________________
Address: _________________________________________________________________________________
City/State/Zip: ___________________________________________________________________________
Phone: ______________________________ Fax: _______________________________________________
Email: ____________________________________________________________________________________
GENERAL INFORMATION
TO REGISTER
PAYMENT INFORMATION
