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Inflammatory Arthritis: Clinical Update Day Date: Saturday, 15 March 2014 Time: 9.30am to 4.00pm (Registration from 9.00am) Venue: Kolling Institute Royal North Shore Hospital Reserve Road, St Leonards NSW 2065

Cost:

$ 155 (Early Bird before 29 November 2013) $ 190 (Standard registration)

Delegate information Title: …………..

First name: …………………………………… Last name: ………………………………………………….

Street Address: …………………………………………………………………………........................................................ Suburb: ……………………………………………………………. State: ……………. Postcode: ……………………………. Phone/ mobile: ……………………………………………….. Email: ……………………………………………………………… Profession: ………………………………………………………. Workplace Name: …………………………………………… Allergies or dietary requirements: ………………………………………………………………………………………………….

Payment details  I enclose a cheque made out to Arthritis NSW for $ ………………  Please charge my Mastercard / Visa for $ ................................. Card Number: ………………. / ……………….. / ……………….. / ……………….. Expiry Date: ……..… / …….…. Name on Card: ……………………………………………………………… Signature: …………………………………………………….

Registration deadline: 28 February 2014 (Early Bird ends 29 November 2013) To register, complete this form with payment details and fax, email or post to: Fax: (02) 9857 3399 Post: Attn: Jenny Ly (Arthritis NSW) Email: jly@arthritisnsw.org.au Locked Bag 2216, North Ryde NSW 1670 Registrations can also be completed online or by phone: Online: www.arthritisnsw.org.au Phone: (02) 9857 3300

Note: Cancellation policy applies. Please contact us for more information.


Health Professional Day Registration form  

Health Professional Day Registration form

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