Australia ICOMOS Secretariat
Cultural Heritage Centre for Asia and the Pacific
Faculty of Arts, Deakin University
221 Burwood Highway
Burwood Vic 3125
Ph: +61 3 9251 7131
Fax: +61 3 9251 7158
austicomos@deakin.edu.au
www.icomos.org/australia
ABN: 85 073 285 798
AUSTRALIA ICOMOS
CREDIT CARD AUTHORISATION FORM
Please fill in the details below & send:
via post
Australia ICOMOS Secretariat
Cultural Heritage Centre for Asia and the Pacific
Faculty of Arts, Deakin University
221 Burwood Highway
Burwood VIC 3125
via fax
via email
03 9251 7158
austicomos@deakin.edu.au
For the Cockatoo Island Event on the 8th November 2008
Names of all ICOMOS members attending*:
1.
2.
4.
5.
TOTAL no. of ICOMOS members
TOTAL cost @ $25 per ICOMOS member
Names of all non-members attending*:
1.
2.
4.
5.
TOTAL no. of non-members
TOTAL cost @ $40 per non-member
TOTAL AMOUNT FOR ALL ATTENDEES
3.
6.
3.
6.
* Please attach a separate page for attendees not fitting in to the above table
Please debit my (please tick):
 VISA
Card number _ _ _
Expiry date
 Mastercard
_/____/____/____
__/__
Name on card ___________________________
Cardholder’s Signature ________________________
Total amount ____________