NCCN Oncology Case Management Program ™ Housing Request Form by JamiePeacock

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									NCCN Oncology Case Management Program™ Housing Request Form
New York Marriott Marquis ($99.00 plus taxes for night of October 1 only)
1535 Broadway ■ New York, NY

Guidelines and Instructions – please read carefully!

NCCN has reserved a limited number of rooms at the New York Marriott Marquis the night
of Thursday, October 1 for the NCCN Oncology Case Management Program™ at the special
rate of $99 plus applicable taxes. These rooms will be made available on a first-received,
first-reserved basis for qualified Program attendees. In order to request and qualify for this
special rate:

   •   Attendee must be registered for the NCCN Oncology Case Management Program no
       later than Tuesday, September 1, 2009.
   •   Attendee must reside outside New York City (the five boroughs).
   •   Attendee must be a nurse (case manager or other role), medical director, or clinical
       pharmacist at a health plan or managed care organization.
   •   Attendee must complete and return the attached Housing Request Form no later
       than Friday, September 4, 2009.

Program registrants who submit this form will be notified regarding the status of their
request within 5 business days. Once all available rooms under this block have
been reserved, people will be advised to contact the New York Marriott Marquis directly for
any accommodation needs. NCCN has negotiated a rate of $269 plus applicable taxes for
additional rooms beyond this special block.

If you are unable to attend the program, you must send your cancellation in writing to
Diane McPherson (mcpherson@nccn.org) no later than Thursday, September 24 to avoid
any penalty charges. Cancellations received after Thursday, September 24, non-arrivals at
the hotel, or those who check-in to a room and then do not attend the actual meeting on
October 2 will be subject to a total penalty charge of $269 plus applicable taxes for the
room reservation. These charges will be directly from NCCN to cover expenses for the
reservation. Questions or concerns regarding accommodations should be directed to Diane
McPherson, 215.690.0266 or mcpherson@nccn.org.

All requests will be processed upon receipt at NCCN and rooms will be provided based on
availability. Those program registrants assigned to a room under this special rate are subject
to penalty charges for not adhering to guidelines and instructions outlined on previous
page. By signing and submitting the attached Accommodations Request Form to NCCN, you
are agreeing to all terms and conditions stated within this document.

Please return attached form by fax to Diane McPherson at 215.565.4141 no later than
Friday, September 4, 2009.
NCCN Oncology Case Management Program™ Housing Request Form
New York Marriott Marquis ($99.00 plus taxes for night of October 1 only)
1535 Broadway ■ New York, NY

Name of Program Attendee: (please print)

Last Name:                                    First Name:

Address:

City:                         State:                   Zip Code:

E-mail Address:

Telephone:

Special ADA (American Disability Act) Needs:
              ______________          ______________          ______________        _______

Credit Card Information:

         American Express              MasterCard                    Visa
Cardholder’s Name:
Billing Address:
City:                         State:                   Zip Code:
Card Number:
Exp. Date:                             Card Verification Number:

Cardholder Signature:

For those eligible for housing, NCCN will provide the above information to the New York
Marriott Marquis. Upon arrival your credit card will be charged for one night’s lodging of
$99 (plus 8.375% New York State Tax, 5.875% New York City Tax, and $3.50 Occupancy Tax)
and any incidental room charges at checkout. You will be asked to provide this credit card
at check-in to cover these costs.

If you are unable to attend the program, you must send your cancellation in writing to
Diane McPherson (mcpherson@nccn.org) no later than Thursday, September 24 to avoid any
penalty charges. Cancellations received after Thursday, September 24, non-arrivals at the
hotel, or those who check-in to a room and then do not attend the actual meeting on
October 2 will be subject to a total penalty charge of $269 plus applicable taxes for the
room reservation. These charges will be directly from NCCN to cover expenses for the
reservation. Questions or concerns regarding accommodations should be directed to Diane
McPherson, 215.690.0266 or mcpherson@nccn.org.

By signing and submitting this Accommodations Request Form to NCCN, you are
agreeing to all terms and conditions stated within this entire document.
Submission of this form does not guarantee you a room at this rate. You will be
contacted through additional correspondence regarding the status of this request.

Requester’s Signature:

Please return this form by fax to Diane McPherson at 215.565.4141 no later than Friday,
September 4, 2009.

Internal use only:
Date Received_________ Date Logged_________ Processing Number: _________ Yes No

								
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