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Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 1 Registration & Housing REGISTER, RESERVE A HOTEL & BOOK COURSES BADGE/NAME INFORMATION Member/Customer ID Number Name* Middle Initial/Name Last/Family Name* Badge First Name Business Name* Department Job Title NPI NUMBER In an effort to assist our industry partners’ compliance with the mandatory reporting provisions of the Sunshine Act, which require electronic disclosure of any “payment or other transfer of value given to a physician” to the Department of Health and Human Services, HRS is requesting that U.S. physician attendees provide their National Provider (NPI) number when registering for HR2013. For more information, please visit the Centers for Medicaid and Medicare Services website at www.cms.gov MAILING INFORMATION Home OR Business Street Address* Street Address 2/Building or Suite Number City* State/Province* Zip/Postal Code* Country* Phone (Day Time)* (country code/city code/number) Mobile Phone (country code/city code/number) Fax (country code/city code/number) Email* EMERGENCY CONTACT INFORMATION Emergency Contact’s First Name* Emergency Contact’s Last/Family Name* Emergency Contact’s Day Time Phone (country code/city code/number)* Third Party Mailings Opt Out Check this box to opt out of providing your contact information to exhibitors. If you do not check this box, your contact information will be provided to Heart Rhythm 2013 exhibiting companies so they may present you with information on related products and services by way of mail. Heart Rhythm 2013 – Communicate Check this box to opt-out of Heart Rhythm 2013 – Communicate. This social networking feature allows Heart Rhythm 2013 registrants to search and contact other registered colleagues before and during the Sessions. The feature will enable communications via e-mail, but your e-mail address will not be disclosed to other registrants. All e-mails will remain Exhibiting companies will not have access to this feature. Special Services Check here if you require special services. Please describe special services: ______________________________________________________ ________________________________________________________________________________ HRSonline.org/Sessions Fax completed registration form with credit card information to 508-743-9636 Mail completed registration forms with full payment to: Heart Rhythm 2013 c/o Convention Data Services 107 Waterhouse Road Bourne, MA 02532 800-748-5052 508-743-0529 SOURCE CODE INFORMATION ____________________________________ Please enter above the Code found on your promotional mailing or email.* Or How did you hear about Heart Rhythm 2013? Advertisement in HeartRhythm Journal Advertisement – print publication Advertisement – website other than HRS Advance Program Email Announcement Facebook Heart Rhythm Society Website Professional Conference Twitter Word of Mouth Other _________________ From where did you get additional information about Heart Rhythm 2013? (Check all that apply) Advertisement in HeartRhythm Journal Advertisement – print publication Advertisement – website other than HRS Advance Program Email Announcement Facebook Heart Rhythm Society Website Professional Conference Twitter Word of Mouth Other _________________ SPECIAL DIETARY NEEDS (Leave blank if not applicable) Kosher Vegetarian Please note: Kosher meals must be requested by May 1, 2013.
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Page 1: Heart Rhythm Society – 34th Annual Scientific Sessions 2013

Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 1

Registration & HousingREGISTER, RESERVE A HOTEL & BOOK COURSES

BADGE/NAME INFORMATION

Member/Customer ID Number

Name* Middle Initial/Name Last/Family Name*

Badge First Name

Business Name*

Department Job Title

NPI NUMBER In an effort to assist our industry partners’ compliance with the mandatory reporting provisions of the Sunshine Act, which require

electronic disclosure of any “payment or other transfer of value given to a physician” to the Department of Health and Human Services, HRS is requesting that U.S. physician attendees provide their National Provider (NPI) number when registering for HR2013. For more information, please visit the Centers for Medicaid and Medicare Services website at www.cms.gov

MAILING INFORMATION ❑ Home OR ❑ Business

Street Address*

Street Address 2/Building or Suite Number

City* State/Province* Zip/Postal Code* Country*

Phone (Day Time)* (country code/city code/number)

Mobile Phone (country code/city code/number) Fax (country code/city code/number)

Email*

EMERGENCY CONTACT INFORMATION

Emergency Contact’s First Name* Emergency Contact’s Last/Family Name*

Emergency Contact’s Day Time Phone (country code/city code/number)*

❑ Third Party Mailings Opt Out Check this box to opt out of providing your contact information to exhibitors. If you do not check this box, your contact information will be provided to Heart Rhythm 2013 exhibiting companies so they may present you with information on related products and services by way of mail.

❑ Heart Rhythm 2013 – Communicate Check this box to opt-out of Heart Rhythm 2013 – Communicate. This social networking feature allows Heart Rhythm 2013 registrants to search and contact other registered colleagues before and during the Sessions. The feature will enable communications via e-mail, but your e-mail address will not be disclosed to other registrants. All e-mails will remain Exhibiting companies will not have access to this feature.

❑ Special Services Check here if you require special services. Please describe special services: ______________________________________________________

________________________________________________________________________________

HRSonline.org/Sessions

Fax completed registration form with credit card information to 508-743-9636

Mail completed registration forms with full payment to:Heart Rhythm 2013c/o Convention Data Services107 Waterhouse RoadBourne, MA 02532

800-748-5052508-743-0529

SOURCE CODE INFORMATION

____________________________________Please enter above the Code found on your promotional mailing or email.*

Or

How did you hear about Heart Rhythm 2013?

❑ Advertisement in HeartRhythm Journal❑ Advertisement – print publication❑ Advertisement – website other than HRS❑ Advance Program❑ Email Announcement❑ Facebook❑ Heart Rhythm Society Website❑ Professional Conference❑ Twitter❑ Word of Mouth❑ Other _________________

From where did you get additional information about Heart Rhythm 2013? (Check all that apply)

❑ Advertisement in HeartRhythm Journal❑ Advertisement – print publication❑ Advertisement – website other than HRS❑ Advance Program❑ Email Announcement❑ Facebook❑ Heart Rhythm Society Website❑ Professional Conference❑ Twitter❑ Word of Mouth❑ Other _________________

SPECIAL DIETARY NEEDS(Leave blank if not applicable)

❑ Kosher❑ VegetarianPlease note: Kosher meals must be requested by May 1, 2013.

Page 2: Heart Rhythm Society – 34th Annual Scientific Sessions 2013

Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 2

Registrantname: _____________________________

HEART RHYTHM 2013 SCIENTIFIC SESSIONS FEE CATEGORIESTheregistrationfeeforHeartRhythm2013includesadmissiontotheMini-Courses,AlliedProfes-sionalsForums,Basic/TranslationalScienceForum,LeadManagementForum,Hands-OnSession,OpeningPlenarySession,Case-BasedTutorials,CoreCurricula,Oral/Poster/ModeratedAbstractPresentationsandFeaturedSymposia,Debates,TranslationalEPSessions,TechnicalExhibits,FeaturedPostersSessionandReception,andtheAwardsCeremonyandPresidents’Reception. An additional feeisrequiredfortheAFSummit,VT/VFSummit,Meet-the-ExpertLuncheons,andtheWomeninEPNetworkingLuncheon.(See descriptions and requirements online at www.HRSonline.org)

HEART RHYTHM 2013 SCIENTIFIC SESSIONS FEE CATEGORIES

Early Through March9

AdvanceMarch10–

May 4

On-Site May5–May 11

qPhysicianMember $755 $865 $895

q Industry Member $755 $865 $895

qScientistMember $395 $485 $495

qAlliedHealthProfessionalMember $395 $485 $495

qAffiliateMember $275 $385 $495

q Emeritus Member $0 $0 $0

qPhysicianNonmember $995 $1,135 $1,155

q Industry Nonmember $995 $1,135 $1,155

qScientistNonmember $785 $895 $915

qAlliedHealthProfessionalNonmember $595 $725 $735

qFellows-in-TrainingNonmember $595 $725 $735

qExhibitingCompanyPersonnelAttendingScientificSessions $785 $885 $915

q Undergraduate Student $175 $175 $175

q Guest $85 $85 $85

GUEST REGISTRATIONIncludesadmissiontotheTechnicalExhibits,FeaturedPostersSessionandReception,andtheAwardsCeremonyandPresident’sReceptionONLY.Guestscannotattendsessionsandarenoteligibleforcredits.Childrenunder16yearsofagemaynotentertheExhibitHallatanytime.PleasecontactCDStoregistermorethanoneguest.

Guest First Name

Guest Last/Family Name

Guest Badge Name

ONE-DAY REGISTRATIONTheone-dayregistrationfeeincludesadmissiontothenon-ticketedsessionsandTechnicalExhibitsheldonthedayofregistrationonly.TheWednesdayfeeincludestheTechnicalExhibitsanddoesnotincludetheAFSummitortheVT/VFSummit.TheSaturdayfeedoesnotincludetheTechnicalExhibits.Ticketedfunctionswithfeesareextraforall registrants. (Chose one day only.)

ONE-DAY Wednesday or Saturday

Thursday or Friday

Members $295 $415Nonmembers $415 $530

REGISTRANT PROFILE * Denotes required field

1. Primary Occupation* (Check one)

q Educatorq Engineerq Hospitalistq Manager/Administratorq Nurseq NursePractitionerq Physicianq PhysicianAssistantq Retiredq Sales/Marketing/ProductDevelopmentq Scientistq Technician/Technologistq Training:Fellow-in-Trainingq Training:MedicalStudent/Intern/Residentq Other:________________

2. Primary Area of Practice/Specialty* (Check one)

q BasicResearchScienceq ClinicalCardiologyq ClinicalElectrophysiologyq ClinicalResearchScienceq Heart Failureq HypertrophicCardiomyopathyq Interventional Cardiologyq PediatricCardiologyq PediatricEPq Surgeryq TranslationalResearchScienceq Other:________________

3. Secondary Area of Practice/Specialty (Check all that apply)

q BasicResearchScienceq ClinicalCardiologyq ClinicalElectrophysiologyq ClinicalResearchScienceq Heart Failureq HypertrophicCardiomyopathyq Interventional Cardiologyq PediatricCardiologyq PediatricEPq Surgeryq TranslationalResearchScienceq Other:________________

4. Primary Work Environment* (Check one)

q AcademicSettingq Associationq EPPrivatePracticeq HealthMaintenanceOrganization/

PreferredProviderOrganizationq Hospital(academic)q Hospital(non-academic)q Industryq Multi-disciplineCardiologyPrivatePracticeq Retiredq Veterans Administrationq Other:________________

5. Do you manage patients with: (Check all that apply)

q AriskforSCAq Atrial Fibrillationq Heart Failureq Other:________________

6. How many of these procedures do you perform annually? (Complete all that apply)

q AF Ablation ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q DeviceInterrogation ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q Devices:ICDs ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q Devices:Pacemaker ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q Devices:CRT ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q LeadExtractions ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q SVT Ablation ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

q VT Ablation ___None ___1–25 ___26–50 ___51–100 ___101–200 ___More than 200

7. Gender q Male q Female q Choose Not to Answer

8. Date of Birth* _________/________/_________ (Month/Day/Year)

Page 3: Heart Rhythm Society – 34th Annual Scientific Sessions 2013

Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 3

TICKETED FUNCTIONS (FEE REQUIRED)REGISTER EARLY! SPACE IS LIMITED!Byselectingticketedfunctionsbelow,youwillbeissuedaticketforeachfunction.AFullScientificSessionsRegistrationoraOne-DayregistrationisrequiredtobeeligibletoselecttheMeet-the-ExpertLuncheonsandtheWomeninEPNetworkingLuncheon.

AF SummitWednesday, May 8, 8 a.m. – 4 p.m. You may select the AF Summit alone or in conjunction with your Scientific Sessions Registration.q AF Summit with Full Registration (Physician/Industry/Scientist/

Emeritus Members), $335q AF Summit with Full Registration (Allied Health Professional,

including Physician Assistant and Hospital Administrator Members), $135

q AFSummitwithFullRegistration(AffiliateMembers),Complimentaryq AF Summit with Full Registration (Physician/Industry/Scientist/

ExhibitingCompanyPersonnelAttendingScientificSessionsNon-members), $445

q AF Summit with Full Registration (Allied Health Professional, Physician Assistant, Hospital Administrator, and Undergraduate StudentNon-members),$235

q AFSummitwithFullRegistration(Fellows-orScientists-in-TrainingNonmembers), $135

q AF Summit only (Physician/Industry/Scientist/Emeritus Members), $525

q AFSummitonly(Affiliate/AlliedHealthProfessional,includingPhysician Assistant and Hospital Administrator Members), $295

q AFSummitonly(Physician/Industry/Scientist/ExhibitingCompanyPersonnelAttendingScientificSessionsNonmembers),$625

q AFSummitonly(Fellows-orScientists-in-Training/AlliedHealthProfessionals, including Physician Assistant and Hospital Administrator, and Undergraduate Student Nonmembers), $395

VT/VF SummitWednesday, May 8, 8 a.m. – 4 p.m. You may select the VT/VF Summit alone or in conjunction with your Scientific Sessions Registration.q VT/VFSummitwithFullRegistration(Physician/Industry/Scientist/

Emeritus Members), $335q VT/VFSummitwithFullRegistration(AlliedHealthProfessional,

including Physician Assistant and Hospital Administrator Members), $135

q VT/VFSummitwithFullRegistration(AffiliateMembers),Complimentary

q VT/VFSummitwithFullRegistration(Physician/Industry/Scientist/ExhibitingCompanyPersonnelAttendingScientificSessionsNonmembers), $445

q VT/VFSummitwithFullRegistration(AlliedHealthProfessional,Physician Assistant, Hospital Administrator, and Undergraduate Student Nonmembers), $235

q VT/VFSummitwithFullRegistration(Fellows-orScientists-in-TrainingNonmembers), $135

q VT/VFSummitonly(Physician/Industry/Scientist/EmeritusMembers),$525

q VT/VFSummitonly(Affiliate/AlliedHealthProfessional,includingPhysician Assistant and Hospital Administrator Members), $295

q VT/VFSummitonly(Physician/Industry/Scientist/ExhibitingCompanyPersonnelAttendingScientificSessionsNonmembers),$625

q VT/VFSummitonly(Fellows-orScientists-in-Training/AlliedHealthProfessionals, Physician Assistant and Hospital Administrator, and Undergraduate Student Nonmembers), $395

Meet-the-Experts LuncheonsThursday, May 9, 12:15 – 1:15 p.m.Friday, May 10, 12:15 – 1:15 p.m.See the Advance Program or visit www.HRSonline.org/SessionsforacompletelistingoftheMeet-the-Expert(ME)Luncheons(spaceislimited;indicatechoicesbyMEnumber).Members:$65eachcourse;Non-members:$85eachcourseq Thursday: 1st choice (ME) ______ 2nd choice (ME) ______ 3rd choice (ME) ______ 4th choice (ME) ______q Friday: 1st choice (ME) ______ 2nd choice (ME) ______ 3rd choice (ME) ______ 4th choice (ME) ______

Women in EP Networking LuncheonPlease select if you plan on attending.Friday, May 10, 12:15 – 1:15 p.m.q Members: $65 qNon-members:$85

FUNCTIONS THAT REQUIRE ADVANCE SELECTIONThefollowingfunctionsareincludedwithyourScientificSessionsregistration. However, to assist us in determining the appropriate room size,pleaseselectthefunctionsyouplantoattend.Aticketwillnotbeissuedtoattendthesefunctions.Seatingwillbeavailableonafirst-come,first-servedbasis.AFullScientificSessionsRegistrationoraOne-Dayregistrationisrequiredtoattendthesefunctions.

Mini-Courses Wednesday, May 8See the Advance Program or visit www.HRSonline.orgforacompletelistingofMini-Courses(MC)(spaceislimited;indicatechoicesbyMCnumber).q 8 – 11 a.m. 1stchoice(MC)____ 2nd(MC)____ 3rd(MC)____q 1 – 4 p.m. 1stchoice(MC)____ 2nd(MC)____ 3rd(MC)____

Allied Professionals Forum I: Introduction to EP for the Novice Allied ProfessionalsAuniqueone-dayprogramfocusingonfundamentalsfortheAlliedHealthProfessionalnewtothefieldandtheHands-OnEducationSession.q Wednesday, May 8, 8 a.m. – 3:30 p.m.

Allied Professionals Forum II: Introduction of Device Therapies for the Novice Allied ProfessionalsAuniqueone-dayprogramfocusingonfundamentalsfortheAlliedHealthProfessionalnewtothefieldandtheHands-OnEducationSession.q Wednesday, May 8, 8 a.m. – 3:30 p.m.

Allied Professionals Forum III: Insights into Managing Complex Arrhythmia and Device Patients for the Advanced Allied ProfessionalsAuniqueone-dayprogramfocusingonadvancedcontentfortheexperiencedAlliedHealthProfessional.q Wednesday, May 8, 8 a.m. – 4 p.m.

Basic/Translational Science Forum: Heart Rhythm Systems PhysiologyPresentedinpartnershipwiththeCardiacElectrophysiologySociety(CES),theforumwillprovideanopportunityforthepresentationanddialogueaboutnewresearchandscience.q Wednesday, May 8, 8 a.m. – 4 p.m.

Registrantname: _____________________________

Page 4: Heart Rhythm Society – 34th Annual Scientific Sessions 2013

Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 4

Lead Management Forumq Wednesday, May 8, 8 a.m. – 4 p.m.

Society Leadership Lunch Forumq Wednesday, May 8, noon - 1 p.m.

Featured Poster Session and ReceptionIncludedintheScientificSessionsregistration,Wednesday-only,andguest registrations. Please select if you plan on attending.q Wednesday, May 8, 6 – 7:30 p.m.

Awards Ceremony & Presidents’ ReceptionIncludedintheScientificSessionsregistration,Friday-only,andguestregistrations. Please select if you plan on attending.q Friday, May 10, 6 – 7:45 p.m.

Final Program Bookq Yes,IwouldliketoreceiveaprintversionoftheFinalProgram.A

voucherwillbeincludedinyourregistrationmaterialtobeexchangedforaFinalProgrambookonsite.

OTHER RELATED PRODUCTSHeart Rhythm 2013 On Demand

q Physician/Industry/Scientist/EmeritusMembers:$375q Affiliate,AlliedHealthProfessional,includingPhysicianAssistantand

HospitalAdministratorMembers:$225q Physician/Industry/Scientist/ExhibitingCompanyPersonnelAttending

ScientificSessions/Non-members:$475q Fellows-orScientists-in-Training,AlliedHealthProfessional,including

PhysicianAssistantandHospitalAdministratorNon-members:$275__________#ofsetsPlease note:PriceswillincreasebeginningMay5,2013.Pleasechooseashippingmethodbelow.(Failuretochoosethepropershippingmethodwilldelayyourshipment.AsecurecarriersuchasFedExwillbeusedforshippingyourproduct.)q NorthAmerica:$15 q AllOtherRegions:$45

HeartRhythm Subscription (theOfficialJournaloftheHeartRhythmSociety)Pleasenote:Ifyouareamember,asubscriptionisalreadyincludedinyour membership.

q Domestic:$195 q International:$219

Registrantname: _____________________________

HOUSING REQUEST

q Nohotelrequired:stayingat/sharingwith______________________

ArrivalDay/Date: ____________________________________________DepartureDay/Date: _________________________________________

Hotel Choices(SeetheAdvance Program or www.HRSonline.org/ Sessionsforlisting;listchoicesinorderofpreference):Choiceisbasedon:q Priceq Location1. ______________________________________________2. ______________________________________________3. ______________________________________________4. ______________________________________________

Room Type:q SingleOccupancy/OnePersonq DoubleOccupancy/TwoPersons/OneBedq DoubleOccupancy/TwoPersons/TwoBedsq TripleOccupancy/ThreePersonsq QuadOccupancy/FourPersonsq SuiteRequest

Special Requests: (Subject to availability)q NonsmokingRoomq Ihaveadisabilitythatwillrequireaccommodationq King Bedq ConciergeLevelq FrequentStayProgramNameandIDNumber:____________________________________________________________________________

Please note:Hotelroomsarelimited.Ifnoneofmychoicesareavail-able,pleasecheckoneofthefollowing:q Do not assign me a room.q Assign me a room at any available hotel.q Assignmearoomatahotelwithasimilarprice.q Assignmearoomatahotelinasimilarlocation.Adepositofonenight’sroomandtaxbyassignedhotelatapplicablerateisrequired.CreditcardswillbechargedonoraroundApril6,2013.

PAYMENT & PROCESSING OF FEES

TOTAL PAYMENT FOR REGISTRATION, FEE-BASED FUNCTIONS, and OTHER RELATED PRODUCTS = $______________Creditcardsarebilledimmediatelyuponreceiptofregistrationform.Checks/MoneyordersmustbeinU.S.fundsanddrawnonaU.S.bank.Checks/MoneyordersmustbemadepayabletoHeart Rhythm Society.

CreditCard:q MasterCard q VISA q AmericanExpress

Card Number

ExpirationDate(MM/YY)

PrintCardholder’sName

Cardholder’sSignature

Refundrequestsmustbesubmittedinwriting(nophonecalls,please)toCDSandreceivedby5p.m.EDT,April12,2013.A$75processingfeewill be withheld.

Register today, visit www.HRSonline.org/Sessions

TOTAL PAYMENT FOR HOTEL = $______________CreditcarddepositwillbebilledonoraroundApril6,2013.

CreditCard:q MasterCard q VISA q AmericanExpress

Card Number

ExpirationDate(MM/YY)

PrintCardholder’sName

Cardholder’sSignature

Cancellationpolicyisnotedontheconfirmationletter.Failuretocancelyourroomwillresultinforfeitureofthedepositpayment.