REGISTRATION


Heritage Hotel Queenstown
 August 5th, 6th, 7th, & 8th, 2010

Register early as numbers may be limited
due to capacity of venue

ONLINE FORM


*Fields marked with an asterisk (*) MUST be completed to send form!


Title:
 * First and Last Name
* E-Mail address:
* Telephone Number:
* Qualifications:
* Department:
* Hospital/Centre:
* State/Province:
* Country:
* Address:
Facsimile Number: 
Companion's Name:


* Registration Fees (Please tick all that apply)
$AUD 795.00    - Full Registrantration
$AUD 600.00    - Subsidised Registrant - Student Perfusionist
$AUD 495.00    - Companion Registration

$AUD 50.00    - Subsidised Activity
If Activy is ticked please select number of person participating

 
Payment Information
 ** Payment by Cheque:
(Please send cheque within 7 days or online application will be invalid!)

Cheques in Australian Dollars and made payable to:-
"Perfusion Downunder Pty Ltd"

Payment by Credit Card:
Visa Mastercard
Card Number:
Expiry Date:
  Month/Year
Name on Card:



** Post cheques to:-
Bernardette Tackney, Cellplex Pty Ltd,
16-18 Hydrive Close, Dandenong South, VIC 3175
Fax No. +61 3 9799 7111, Telephone +61 3 9799 7444
E-mail: btackney@cellplex.net
Registrations may be limited due to capacity of the venue. Registrants must be primary practising clinicians. The Organising Committee reserves the right to accept or decline applications for registration.







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2010
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