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CONF E R ENCE R EG I S TRAT I ON
Register online at
www.hbma.org
or return this form with your payment to HBMA via fax or mail.
Please submit a separate registration form for EACH attendee.
Member Organization _____________________________________________ Member #: _________________ CHBME:
Yes
No
Name: _______________________________________________ ______________________________________________________________________
First Name
Last Name
Title: _______________________________________________________________________________________________________________________
Company Name: _____________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: _________________________________________________________ State/Province:________________ Zip: __________________________
Country: ____________________________________________________________________________________________________________________
Phone: __________________________________________________________ Fax: _______________________________________________________
Email: ___________________________________________________________ Website: __________________________________________________
In case of emergency, please contact: _______________________________ Emergency contact phone #: _________________________________
REGISTRATION
Register and make your hotel reservations early! Space is limited to 55 participants.
October 24-26, 2013 • Chicago, IL
Please complete the following:
I will attend the:
Thursday Working Lunch
Friday Working Lunch
Thursday Opening Reception
Friday Networking Reception
I understand that full refund of the registration fee, less a $150 administrative fee, will be granted only
upon a written request received by HBMA on or before Monday, Septemeber 24, 2013.
I have special needs, including dietary. Please contact me.
I am a new HBMA member
This is my first HBMA conference
REGISTRATION FEE AND PAYMENT INFORMATION
This conference is open to HBMA members only.
Registration Fee: $1295.00
Full payment MUST accompany your registration. Register on-line at
www.hbma.org
. You may also fax this form with
credit card information to (949) 376-3456 or mail along with your payment to HBMA. The fee includes conference
materials, breakfast and refreshments breaks, lunches, and receptions.
Registration Fee Total $1295.00
Check # ______________
Visa
MasterCard
AMEX
Credit Card Number _____________________________________________________ Exp. Date ______________ CVV# ____________
Name as it Appears on Card (please print) ____________________________________________________________________________
Authorized Signature _______________________________________________________________________________________________
HBMA, 1540 S. Coast Hwy, Ste 203, Laguna Beach, CA 92651
Phone: 877-640-4262
|
Fax: 949-376-3456
|
www.hbma.org
CHICAGO, ILLINOIS |
OCTOBER 24-26, 2013