123, Red Hill Qld 4059. Phone: (07) 3872 2222. Privacy information: AMA Queensland's primary purpose of collecting perso
JDC 2017 registration form R E G I S T R AT I O N C AT E G O R Y
D A Y - O N LY R E G I S T R AT I O N
B OT H - DAY R E G I S T R AT I O N
Early-bird rates end Friday 28 April 2017.
(Sunday ticket incl. wine and cheese networking event)
(incl. Cocktail party and wine and cheese networking event)
M E M B E R R AT E S
Early-bird
Standard
Early-bird
Standard
Student and intern
$165
$190
$295
Sat
Doctor in training (years 2 - 5) (DIT) Senior doctors (Snr Dr)
Sun
Sat
Sun
Sat
Sun
Sat
$335
$80
$20
$335
$390
$80
$20
$390
$465
$80
$20
Sun
$245
$215 Sat
WINE AND CHEESE NETWORKING E V E N T O N LY
Sun
$215
$190 Sat
COCKTAIL PA RT Y TICKET O N LY
Sun
N O N - M E M B E R R AT E S
Note early-bird rates are not available to non-members, but you can join online at amaq.com.au to become a member and save!
Student and intern
N/A
$235 Sat
Doctor in training (years 2 - 5) (DIT)
N/A
Senior doctors (Snr Dr)
N/A
$265 Sat
AT T E N D E E D E TA I L S :
$425
$90
$40
N/A
$465
$90
$40
N/A
$560
$90
$40
Sun
$290 Sat
N/A Sun
Sun
(Please complete all sections and print in block letters)
Name: ( Dr / Mr / Ms / Mrs / Miss ) Registration type:
Student
Mobile:
Member (member no): Intern
DIT
Snr Dr
Non-Member
Practice / Hospital / Company name:
Office Phone:
Email:
Postal address: Dietary requirements:
Cocktail party: (important, please tick)
(Two day attendees please confirm attendance)
Attending
Wine and cheese event: (important, please tick)
Not attending
Attending
Not attending
(Two day and Sunday attendees please confirm attendance)
ADDITIONAL SOCIAL FUNCTION TICKETS: Additional cocktail party tickets For one day participants and
Name/s:
Additional wine and cheese tickets For Saturday day participants and
participant’s partners $80 for members, $90 for non-members
participant’s partners
$20 for members, $30 for non-members
PAY M E N T O P T I O N S : Credit card:
Visa
Mastercard
Cardholder’s name: Direct deposit: Contact the events team on (07) 3872 2222.
Submit registration form Email: registrations @amaq.com.au
AMEX amount $
Card number:
Name/s:
Exp date: Signature:
/
CVV:
Fax:
(07) 3872 2280
Post: AMA Queensland, PO Box 123, Red Hill Qld 4059 Phone: (07) 3872 2222
Privacy information: AMA Queensland’s primary purpose of collecting personal information on this form is to process your purchase. In providing your details you consent to your personal details being used in the manner indicated. ABN: 17 009 660 280
