9/19/2022      – You will have until midnight on this day to reserve rooms in your block at the discounted rate.  After this date, if any rooms are still available at the hotel they will likely be at a higher rate.

Registration Form – Surgery Center Infection Control Practices: Evidence Based Practices for the ASC

October 6th & 7th, 2022 If paying for more than one registrant by credit card, please submit all registrations together.

• Surgery Center Name*
• Purchasers Name as it appears on Credit Card or Paypal*
  This will allow us to link account used for payment with guest that are in attendance from your center.
• Surgery Center Address*
  Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Phone
• Attendees in registration*
  1234

• Enter Attendee Names, License #, and Email

• Attendee #1 Name*
  First Last
• License #*
• Email*
• Attendee #2 Name*
  First Last
• License #*
• Email*
• Attendee #3 Name*
  First Last
• License #*
• Email*
• Attendee #4 Name*
  First Last
• License #*
• Email*
• Infection Control Seminar (add quantity)*
  Price: $500.00 Quantity:
  No refunds will be given after September 15. A $50 processing fee will be charged for all cancellations. Cancellations must be made in writing.
• Payment Method
  PayPal Checkout
  MasterCard

  Visa

  Supported Credit Cards: MasterCard, Visa

  Card Number Expiration Date Security Code   Cardholder Name