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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
