Fundamentals of Database Systems for
HIMs – Enrolment Form
Personal Details
All information will be treated confidentially in accordance with our privacy policy which is available on
our website. This information will NOT be sold on to or used by any third party.
HIMAA Membership No. (if you are a member)
Title
Given Names
Surname
Female
Male
Date of Birth
/
/19
Home Address (or Post Office Box if applicable)
State
Postcode
Country
Phone
incl area code
Fax
incl area code
Mobile
email
Business Address
Position
Department
Organisation
Address
State
Postcode
Country
Phone
incl area code
Fax
incl area code
email
Preferred email address
Home
Business
(please tick )
DBMS001 Fundamentals of Database Systems for Health Information Managers
This is an online course. You will be provided with login details upon payment of the
appropriate enrolment fee. Do you currently use any of the following (please tick all that
apply):
Windows version 7 / 8 / XP
Apple Mac
Laptop computer
Tablet Computer (iPad/Android etc)
Microsoft Access
Apple Filemaker / Filemaker Pro
Payment MUST accompany enrolment form
(please tick () one box only)
Enclosed is payment for
Non-members
Non-member rate for course
Fees are in Australian dollars
$780.00
Fees are in Australian dollars
$480.00
Financial Members (HIMAA)
Member rate for course
Cheques made payable to: Health Information Management Association of Australia Limited
EFT payment - for banking details email education@himaa.org.au
MasterCard
Visa
American Express
Please note a
surcharge of
2% applies to
payments by
credit card
Card No.
Expiry Date
/
Cardholder’s Name
Cardholder’s Signature
Organisation
(If business credit card)
Please invoice my organisation. Billing details (if different to the business address on page 1)
Contact _______________________________________
Phone (
)_____________________________
Organisation ____________________________________________________________________________
Billing Address
Email __________________________________________________________________________________
Where to send your enrolment form and payment
The Manager, IMIT and Professional Development Services
Locked Bag 2045 North Ryde NSW 1670 Australia
Phone + 61 2 9887 5898
Fax + 61 2 9887 5895
Or give it to staff at the HIMAA booth at the conference.
email information@himaa.org.au
Filename: Enrolment_OS_Comprehensive_Medical_Terminology
Version 1.4
Date for review: Sept 2015
Page 3 of 4
Release date: Sept 2014