CONFERENCE Registration WEB FORM

Please complete all fields* and use N/A where appropriate.
Registration payment is by credit card: Visa and MasterCard only.
Please refer to the conference cancellation and refund policy.

1 Personal Details

Title

Family Name *

Preferred First Name *

Email Address *

Day Time Telephone (include area code) *

Mobile *

Hospital/University/Institution *

Location *

Position *

Specialty *

Are you an ASG/ASSG Member?*
Yes No

Membership is free of cost, renewal or obligation and entitles you to attend the AGM at the Conference: after you have registered join online.

2 Conference and Dinner

The Registration fee of $150 includes attendance at both days of the conference and the conference dinner on the Saturday night at the Melbourne Club (dress code is jacket and tie for men).

Conference - Saturday 15 October and Sunday 16 October *

I will attend on both Saturday and Sunday
I will attend on Saturday only
I will attend on Sunday only

Dinner - Saturday 15 October *

I will attend the dinner
I will not attend the dinner
My partner will accompany me (additional $150)

Dinner - Partner Name

Special Requirement

Please indicate any physical assistance, dietary or other requirements.

Poster Abstract *

I will submit a poster abstract
I will not submit a poster abstract

3 Payment

The registration fee is $150 or $300 if your partner is attending the dinner.

Please note that this fee is processed through the Australian Orthopaedic Association on behalf of the Australian Sarcoma Group. Credit card processing may take up to 2 weeks and you will receive a tax invoice following payment. Please contact the Conference Co-ordinator for any payment inquiries 1800 177 657.

Please note: All data entered through this form will be processed via a secure connection.

Credit Card

Card Type *

Name on Card *

Card Number *

Card Expiry *

CCV Number *

Amount * $150.00 $300.00

Registrant Name (for tax invoice)*

Enter Word Verification in box below *

Please note that you will receive a notification via email confirming that your registration has been received.

Annual Sarcoma Conference
15 to 16 October 2011
St Vincent's Public Hospital, Melbourne

1 Personal Details

2 Conference and Dinner

3 Payment

4 Administration Usage Only

Annual Sarcoma Conference 15 to 16 October 2011 St Vincent's Public Hospital, Melbourne

1 Personal Details

2 Conference and Dinner

3 Payment

4 Administration Usage Only

Annual Sarcoma Conference
15 to 16 October 2011
St Vincent's Public Hospital, Melbourne