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2014 Ambulatory Care Conference and Summit
March 3–4, 2014 | The Westin Galleria Dallas | Dallas, Texas

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2014 Ambulatory Care Conference and Summit

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2014 Ambulatory Care Conference and Summit

  1. 1. 2014 Ambulatory Care Conference and Summit March 3–4, 2014 | The Westin Galleria Dallas | Dallas, Texas Register in advance and SAVE! Register at www.ashp.org/ambulatorycareconference14 Early Bird Deadline: January 17, 2014 (Rates increase January 18, 2014) Premeeting Registration Deadline: February 14, 2014 REGISTRATION INFORMATION Please provide home and business information and check preferred address for correspondence. ASHP ID Number (if applicable):____________________ Name______________________________________________ FIRST MIDDLE LAST Title: ________________________________________ Name for Badge:______________________________________ Home Address:____________________________________________________________________________________ STREET CITY STATE ZIP Business Name:___________________________________________________________________________________ Business Address:_________________________________________________________________________________ STREET CITY STATE ZIP Daytime Phone: ________________________________ Fax:_______________________________________________ E-mail (required for meeting confirmation):______________________________________________________________ Course fees q Additional tax-deductible donation to the ASHP Research and Education Foundation $390 $590 $475 $725 $350 $525 $290 $390 q A Director q B Associate or Assistant Director q C Clinical Coordinator q D Other Supervisory Position q E Staff Pharmacist q F Clinical Pharmacist–General q G Clinical Pharmacist–Specialist q H Faculty q I Student q J Resident q K Technician q N Other: ____________________________ METHOD OF PAYMENT Please check one. q Members (Early Bird–before Jan. 17) q Non-Members (Early Bird–Before Jan. 17) q Members (After Jan. 18) q Non-Members (After Jan. 18) q One Day Member q One Day Non-Member q Resident/Student/Tech Members q Resident/Student/Tech Non-Members What is your primary position? (please check one) $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ ______________ TOTAL FEES $ _____________ Registration includes: Breakfasts (2), Lunches (2), and a Reception. ACCS14 q Enclosed is my check or money order made payable to ASHP and drawn on a U.S. Bank. q Enclosed is my U.S. purchase order number #_________. Please issue invoice. q Charge $______ to my: q MasterCard q VISA q AmEx q Discover Card #: __________________________________ Exp. Date: _________ Signature:__________________________________________________ B y authorizing this charge, I certify that the above registration information is true and correct, and agree to be responsible for any additional charges. FOUR WAYS TO REGISTER q ONLINE www.ashp.org/ambulatorycarconference14 (It’s the quick and easy way to go!) BREAkOUT SESSIONS: Please select one each day Monday, March 3, 2014 I 2:00 p.m.–5:00 p.m. (3 hours in duration) q CALL TOLL-FREE 1-866-279-0681, Mon.–Fri. 8 a.m.–6 p.m. EST International: 001-301-664-8700 q Breakout 1: (BK1A) It Starts with Us: Defining Ambulatory Care q FAX registration form to 1-301-657-1251 q Breakout 2: (BK2A) Navigating the Future: Patient Care Delivery and q MAIL registration form with check or money order payable to ASHP. Checks must be drawn on a U.S. bank in U.S. funds. ASHP Payment Center, P.O. Box 17693, Baltimore, MD 21297 Integration q Breakout 3: (BK3A) Develop the Possibilities: Sustainable Business Models q Breakout 4: (BK4A) Make It Matter: Outcomes Evaluation Tuesday, March 4, 2014 I 9:20 a.m.–12:20 p.m. (3 hours in duration) q Breakout 1: (BK1B) It Starts with Us: Defining Ambulatory Care q Breakout 2: (BK2B) Navigating the Future: Patient Care Delivery and Intergration q Breakout 3: (BK3B) Develop the Possibilities: Sustainable Business Models q Breakout 4: (BK4B) Make It Matter: Outcomes Evaluation Registration Cancellation and refunds To receive a full-meeting registration refund, confirmed registrations must be cancelled in writing and mailed or faxed on or before February 14, 2014 (postmark or fax date). Written cancellations postmarked or faxed February 15 through March 2 will be subject to a $50 handling charge. Refunds will be issued only for cancellations postmarked or faxed before March 3. ARRANGEMENTS FOR SPECIAL ASSISTANCE If you have any disability for which you may require an auxiliary aid or special service while attending this meeting, please contact: Jessica Cremer at ASHP, 301-664-8616 Please Note: Payments to ASHP are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible under other provisions of the Internal Revenue Code. Only additional donations to the ASHP Research and Education Foundation are tax deductible. reaoutessions

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