Register here

6 downloads 518 Views 486KB Size Report
10. Member. Non-member. Total attendees: Total amount: $. Payment details: Credit card: Visa. Mastercard. AMEX Amount: $
BOOKING FORM Date Friday 16 June 2017

Time 6.30pm – 11pm

Venue Marquee, Victoria Park Golf Club, 309 Herston Road, Herston

Cost AMA Queensland members $125 Non-members $155 Group booking (table of ten) $1,200

Attendee details:

Name: Dr / Mr / Ms / Mrs / Miss Member number:

Member

Non-member

Organisation:

Office Phone:

Mobile:

Email:

Postal address:

Dietary requirements:

Additional attendees and group bookings:

Please complete the table below with the names of all guests on your table. Name

Member / Non-member

1.

Member

Non-member

2.

Member

Non-member

3.

Member

Non-member

4.

Member

Non-member

5.

Member

Non-member

6.

Member

Non-member

7.

Member

Non-member

8.

Member

Non-member

9.

Member

Non-member

10.

Member

Non-member

Total attendees:

Dietary requirements

Total amount: $

Payment details: Credit card:

Visa

Mastercard

AMEX

Amount: $

Card number:

Expiry date:

Cardholder’s name:

/

CCV:

Signature:

Direct deposit: Contact the Events Team on (07) 3872 2222.

Submit booking form

Email: [email protected] Fax:

(07) 3856 4727

Mail:

PO Box 123, Red Hill QLD 4059

For any enquiries, please contact the Events Team on (07) 3872 2222.

Preferred Medical Indemnity Provider

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