information on this form is to process your purchase. In providing your details you consent to your personal details bei
P R I VAT E P R AC T I C E & MEDICO-LEGAL CONFERENCE 2017
Registration Form F I R S T AT T E N D E E Name: Dr / Mr / Ms / Mrs / Miss (Please circle)
R E G I S T R AT I O N C AT E G O R Y
O N E D AY
Early-bird member (Ends 25 August 2017)
$290
$560
Member standard
$350
$680
Non-member
$450
$880
AMA Queensland Member
Non-member
AMA Queensland member number In the employ of Dr: Practice name:
B OT H D AY S
Registration price inc GST
Position title: Office Phone:
(Friday / Saturday)
Group Bookings: A 10% discount applies for four or more registrations. Contact the Events team on (07) 3872 2222 to apply.
Mobile:
Email address: Postal address:
STREAM SELECTION:
Dietary requirements:
A D D I T I O N A L AT T E N D E E S
Practice essentials masterclass Friday 6 October 1pm – 2.30pm
Name: Dr / Mr / Ms / Mrs / Miss (Please circle) AMA Queensland Member
Non-member
Position title: Email address: Dietary requirements: Name: Dr / Mr / Ms / Mrs / Miss (Please circle) AMA Queensland Member
Practice essentials masterclass Friday 6 October 10.30am – 12pm
Non-member
Or
Practice accelerator masterclass Friday 6 October 1pm – 2.30pm
Practice management stream Saturday 7 October 11am – 12pm
Or
Private practice stream Saturday 7 October 1pm – 2pm
Or
Medico-legal stream Saturday 7 October 11am – 12pm
Medico-legal stream Saturday 7 October 1pm – 2pm
PAYMENT Credit card:
Position title: Email address:
Visa
Mastercard
Dietary requirements:
Amount: $
Name: Dr / Mr / Ms / Mrs / Miss (Please circle)
Card number:
Expiry date: AMA Queensland Member
Or
Practice accelerator masterclass Friday 6 October 10.30am – 12pm
Non-member
/
Amex
CCV:
Cardholders name:
Position title:
Signature:
Email address:
Direct deposit: Contact the events team on (07) 3872 2222.
Dietary requirements:
Submit registration form: Email:
[email protected] Fax:
(07) 3856 4727
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