Registration Form - AMA Queensland

4 downloads 211 Views 111KB Size Report
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