jdc 2018 registration form - AMA Queensland

JDC 2018 REGISTRATION FORM COCKTAIL PARTY TICKET ONLY

WINE AND CHEESE TICKET ONLY

$340

$85

$20

$340

$395

$85

$20

$395

$470

$85

$20

REGISTRATION CATEGORY (Early-bird rates end Friday 20 April 2018)

DAY-ONLY REGISTRATION

BOTH-DAY

MEMBER RATES

Early-bird*

Standard

Early-bird

Standard

Student and intern

$170 Sat

Sun

$195 Sat

Sun

$295

Doctor in training (years 2 - 5) (DIT)

$195 Sat

Sun

$220 Sat

Sun

Senior doctors (Snr Dr)

$220 Sat

Sun

$250 Sat

Sun

NON-MEMBER RATES

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

$260 Sat

Doctor in training (years 2 - 5) (DIT)

N/A

Senior doctors (Snr Dr)

N/A

REGISTRATION (incl. Cocktail party)

N/A

$440

$95

$40

$275 Sat Sun

N/A

$470

$95

$40

$310 Sat

N/A

$560

$95

$40

Sun

Sun

ATTENDEE DETAILS: (Please complete all sections and print in block letters) Name: ( Dr / Mr / Ms / Mrs / Miss ) Registration category:

Student

Phone:

AMA Queensland Member Intern

DIT

Snr Dr

Non-Member

Practice / Hospital / Company name:

Mobile:

Email:

Postal address: Dietary requirements:

Wine and cheese event: (important, please tick)

Cocktail party: (important, please tick) Attending

Not attending

Attending

Not attending



(Two day attendees please confirm attendance)

(Two day and Sunday attendees please confirm attendance)



Free Yoga session: (important, please tick)

Free Running session: (important, please tick)

Attending



Not attending

Attending

(Attendees please confirm attendance)

Not attending

(Attendees please confirm attendance)

ADDITIONAL SOCIAL FUNCTION TICKETS: Additional cocktail party tickets For one day participants and participant’s partners $85 for members,

Additional wine and cheese tickets

Name/s:

For Saturday day participants and participant’s



partners $20 for members,



$95 for non-members



Visa

Mastercard



$40 for non-members

PAYMENT OPTIONS: Credit card:

Name/s:

SUBMIT REGISTRATION FORM Email: registrations

AMEX amount $

Card number: Cardholder’s name:

@amaq.com.au Exp date:

/

CVV:

Signature:

Direct deposit: Contact the events team on (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

Fax:

(07) 3872 2280

Post:

AMA Queensland, PO Box 123, Red Hill Qld 4059

Phone: (07) 3872 2222