Viruses in May 2016 Speaker Registration Form
Thursday 5 – Saturday 7 May 2016 | The Carrington Hotel, Katoomba NSW
Registration Form
Please fill out the form below and return to rachelj@rcpa.edu.au.
RCPA ID (optional)
Details
Prefix
First Name
Last Name
Organisation
Address
City
State
Email
Phone
Post Code
Speaker Registration (incl. GST)
Speaker Registration is complimentary.
Please select which day/s you are attending:
(If not indicated, it will be assumed speakers are only attending the day they are presenting)
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Thursday 5 May
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Friday 6 May ☐ Saturday 7 May☐
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Total: Complimentary
RSVP Buffet Dinner - Thursday 5 May 2016
☐Yes, I am attending (complimentary with registration)
☐Yes, I would like an additional Guest Ticket (No cost) = x ______
Total: Complimentary
RSVP Conference Dinner - Friday 6 May 2016
☐Yes, I am attending (complimentary with registration)
☐Yes, I would like an additional Guest Ticket ($88.00 AUD) = x ______
Total: $__________
Grand Total: $_________
Payment
Credit Card
Card Number
Expiry
MasterCard ☐ Visa ☐ AMEX ☐
☐☐☐☐ ☐☐☐☐ ☐☐☐☐ ☐☐☐☐
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☐☐ ☐☐
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Signature
Cheques
Enquiries
Payable to RCPA
Royal College of Pathologists of Australasia
Durham Hall, 207 Albion Street
Surry Hills NSW 2010
Rachel Johnson
Phone 02 8356 5852 | Fax 02 8356 5828
Email rachelj@rcpa.edu.au
Website www.rcpa.edu.au/events