Viruses in May 2016 Delegate Registration Form
Thursday 5 – Saturday 7 May 2016 | The Carrington Hotel, Katoomba NSW
Registration Form
Register online with your RCPA ID number or fill out the form below and return to rachelj@rcpa.edu.au.
Registration Closes Friday 29 April 2016. No refunds after this date.
RCPA ID (optional)
Details
Prefix
First Name
Last Name
Organisation
Address
City
State
Email
Phone
Post Code
Full Registration (incl. GST)
Full Registration
RCPA Trainee/ ASM Member
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$792.00 (including social events)
Total: $__________
$682.00 (including social events)
Buffet Dinner - Thursday 5 May 2016
☐Yes, I am attending (complimentary with registration)
☐Guest Tickets (No cost) = x ______
Total: Complimentary
Conference Dinner - Friday 6 May 2016
☐Yes, I am attending (complimentary with registration)
☐Guest Tickets ($88.00 AUD) = x ______
Total: $__________
Grand Total: $_________
Payment
Credit Card
Card Number
Expiry
MasterCard ☐ Visa ☐ AMEX ☐
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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