Fax Completed Form (2 Pages) to +61 (0) 8 8379 8177
Total Page：16
File Type：pdf, Size：1020Kb
CleanUp 2015 Group Registration Form
Organisation Name of person co-ordinating registrations Position Held
Postal Address
City State Postcode
Telephone Email (for tax invoice and receipts)
REGISTRATION
Registration Fees: Group registration fees only apply when 5 or more delegates employed by the same organisation are registered at the same time.
Category Earlybird Standard Late Registration Group full registration $1345 $1445 $1545 Pre-conference Workshops and Post-conference Site Visit Full Day $650 $650 $650 Half Day $350 $350 $350 Site Visit $80 $80 $80
Earlybird registration close: 31 July 2015; Standard registration close: 31 August 2015; Late registration open: 1 September 2015
PAYMENT ABN: 60 383 512 852 All fees are in Australian Dollars and include GST
Registration fee: $ x ______delegates = $
Workshop fee:
Full day workshop: $ 650.00 x ______delegates = $ Total Fee Payable Half day workshop: $ 350.00 x ______delegates = $
Site visit fee: $ 80.00 x ______delegates = $
Conference dinner $ 160.00 x ______delegates = $
TOTAL PAYABLE: $______
Credit card payment Card Type (Visa, MasterCard or American Express) Card number
Expiry date
Cardholder name
Cardholder signature or Please send me an invoice or EFT: Bank of South Australia BSB: 105-146 Account #: 026 265 440 Account Name: Cleanup Conference (Please include organisation name on transfer) DELEGATE DETAILS Please complete details for each person attending and indicate which Workshop or Site Visit each person is attending
Conference Workshop(s) Dinner Site Visit First Name Last Name State Email (you must complete this field) Special Requirements (dietary, etc) Indicate (Indicate # Indicate site name workshop # of tickets)
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Please email completed form (2 pages) to [email protected] or
Fax completed form (2 pages) to +61 (0) 8 8379 8177
Conference Secretariat: Plevin and Associates Pty Ltd PO Box 54 Burnside South Australia 5066 Tel: +61 8 8379 8222 Fax: +61 8 8379 8177 Email: [email protected]