PERFUSION DOWNUNDER
The Heritage Resort, Queenstown, New Zealand
August 6^th, 7^th, & 8^th, 2009
Registration and Contact Information
Fields marked with an asterisk (*) must be completed

Title: *		Last Name: *
First Names: *
Qualifications: *
Department: *
Hospital / Centre: *
State / Province: *					Country: *
Address: *
E-mail Address: *
Telephone Number: *
Facsimile Number:
Companions Name:

Registrant Details: (Please indicate no. required)

Type of Registration	$ Cost	Number
Full Registrant - Perfusionist/Scientist/ Surgeon/ Anaesthetist/ Nurse/ Allied Health¹ 1	AUD $745.00
Subsidised Registrant - Student Perfusionist 1	AUD $600.00
Companion Registration Fee 2	AUD $495.00

1	Registrations received after 12th July will be AUD$845.00
2	Registration fee includes Thursday Night - pre-registration welcome drinks / Friday – lunch & cocktail party dinner / Saturday – lunch & formal dinner

Payment Information
Payment by Cheque:   (Australian Dollars.)
   Please make in payable to -   "Perfusion Downunder Pty Ltd"
Payment by Credit Card:
       1 Visa  1 MasterCard
Card Number:   _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
Expiry Date:   _ _ / _ _
Name on Card:  ______________________________

Please return this form to:
Bernardette Tackney, Cellplex Pty Ltd,
16-18 Hydrive Close, Dandenong South, VIC 3164
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.