Registration form, ATSILIRN Conference 17th-18th November 2010
Tax Invoice (ABN) 94 119 934684
This registration form, upon proof of payment, becomes a Tax Invoice. Register NOW by returning
this form via facsimile or post.
Title (Dr/Mrs/Mr/Ms/Professor):________
First name:__________________________ Last name:________________________
Institution/employer:____________________________________________________
Postal Address:__________________________________________________________
City/Town:__________________________ Postcode:_________________________
Telephone:__________________________ Fax:______________________________
Email:__________________________________________________________________
Type of Registration
Early bird (before 31st July)
Full cost
Late registration (after 30th September)
Day registration
Dinner (extra ticket for non-registered guest)
Registration Fee $AUD
300
350
400
200
70
Members Fee $AUD
250
300
350
150
Please indicate your attendance at the following functions which are included in the Conference
Registration Fee:
 Yes
ATSILIRN General Meeting
Conference Dinner Wednesday 17th November 2010
Extra guest $70
 YES
 No
 NO
Special dietary requirements: _____________________________________________________
Registration fee amount: ________
Send your registrations to:
Pat Brady
GPO Box 553
CANBERRA ACT 2601
FAX :02 6261 4287
Total: _________