Issue link: https://beckershealthcare.uberflip.com/i/704577
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 This program is approved for 11 hours of AEU credits by BASC Provider #3672. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of The Institute for Medical Studies and Becker's Healthcare. The Institute for Medical Studies is accredited by the ACCME to provide continuing medical education for physicians. The Institute for Medical Studies designates this live activity for a maximum of 12.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. For information on additional credits offered please visit our website. www.beckersasc.com/annual-ambulatory-surgery- centers-conference/credits.html 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 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:_____________________________________________________ E-mail: _____________________________________________________________________________________________ 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.