Welcome to Perfusion Downunder Winter Meeting 2012

PERFUSION DOWNUNDER WINTER MEETING 2012

Thursday 2nd - Sunday 5th August 2012

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:

$AUD 890.00 (Inclusive of GST)   - Full Registrant - Perfusionist
$AUD 700.00 (Inclusive of GST)   - Subsidised Registrant - Student Perfusionist
$AUD 890.00 (Inclusive of GST)   - Full Registrant - Scientist/ Surgeon/ Anaesthetist/ Nurse/ Allied Health
$AUD 495.00 (Inclusive of GST)   - Companion Registration
$AUD 50.00 (Inclusive of GST)   - Subsidised Activity

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.

Proudly sponsored by
Cellplex Logo