Registration - Perfusion Downunder Winter Meeting 2010

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    - Subsidized 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.

2010
Register Now

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