AUSTRALASIAN COLLEGE OF PHLEBOLOGY 2007 REGISTRATION FORM


Stamford Plaza Double Bay
AUSTRALIA
18th - 21st September 2007

PERSONAL DETAILS
Title:
First Name:
Surname:
Company / Clinic:
Company / Clinic Suburb:
Preferred Contact Address:
Suburb:
City / Town :
Postcode:
Email Address:
Phone Bus:
Fax:
Mobile:

OTHERS ATTENDING
First Name: Surname:
TOTAL ATTENDING
Adults
Children (0-15yrs)
Cot Needed? Yes No

SPECIAL REQUESTS
FILL IN DETAILS OF ANY SPECIAL REQUESTS (eg dietary)
WE WILL DO OUR BEST TO ADDRESS THESE:

REGISTRATION CONFIRMATION
All delegates will receive written confirmation of their conference registration once received and payment has been processed. Registration and accommodation requests will not be processed unless accompanied by full payment.

CANCELLATION POLICY
Cancellations can only be received in writing, and incur a loss of 50% of registration fees up until Friday 27th July 2007. Later cancellations forfeit registration fees paid. Any other refunds are at the discretion of the organisers. Substitutions can be made. Please advise substitutions in writing. Substitutions are only valid when confirmed by Conference Matters.

PRIVACY
The contact information supplied on the registration form will be distributed to the attending industry sponsors. Please advise in writing if you do not wish to be included on this list.
 
REGISTRATION FEES INCL GST (AU$) NO. ATTENDING
Basic Phlebology Certificate Course - Tue 18th September
Members / Non Members
@ $550pp
Affiliate Members
@ $165pp
Conference Wednesday 19th - Friday 21st September
Delegate ACP Members
@ $1200pp
Delegate Non Members
@ $1400pp
Less early bird discount of $150 if booked before Wednesday 15 August 2007
Not applicable
Affiliate Members
@ $440pp
Company Reps
@ $440pp
Spouse (other adult non medical)
@ $250pp
OR DAILY REGISTRATION
ACP Members Wednesday
@ $600pp
ACP Members Thursday
@ $600pp
ACP Members Friday
@ $600pp
Non Members Wednesday
@ $700pp
Non Members Thursday
@ $700pp
Non Members Friday
@ $700pp
Late registration fee of $150 if booked after 31 August 2007
Total Registration Fees (Total_A)

SOCIAL & FUNCTION PROGRAMME
Welcome Cocktail Function Wednesday 19 September
No. attending
NO FEE
Breakfast Session - Phlebology Alabama Style Thursday 20 September
No. attending @ $55pp
Special Event - Being Louis Grondin Friday 21 September
No. attending @ $55pp

Additional Conference Dinner Tickets Saturday 22 September

Additional tickets required @ $220pp
(Total B)

ACCOMMODATION - STAMFORD PLAZA DOUBLE BAY
Accommodation Needed
Yes No
Accommodation Type
King Bed Two Twin Beds
 
Smoking Non-smoking
Arrival Date
Departure Date
Total Number of nights
Superior Room $210 p/night
No. of rooms
Deluxe Room $260 p/night
No. of rooms
(Total Total_C)

CONCURRENT WORKSHOPS
Thursday 20 September
Diagnostic Workshops
@ $55pp
Friday 21 September
Expert Workshops
@ $55pp
(Total_D)
Total A + B + C + D
(fees include tax)

PAYMENT DETAILS (ARBN 125 214 217)
1. Credit Card ARBN 125 214 217
I authorise Conference Matters to charge my
Visa Mastercard AMEX
Card Number
Card Holders Name
Card Expiry Date  / 
2. Cheque
(AUD) payable to: Conference Matters, post to Conference Matters, Phlebology Conference 2007, PO Box 1661, Whangarei, New Zealand.
3. Request Invoice
Please send me an invoice for the above amount,
Including the following purchase order number, if required;
Purchase Order Number
4. Electronic Transfer
Account Name: Conference Matters
Country: Australia
Particulars: Company Name
SWIFT Code: CTBAAU2S
Payee Code: Your reference
Bank Name: Commonwealth Bank Australia
BSB: 062000
Account number: 12333204
Reference: PHLEBOLOGY 2007