CONFERENCE REGISTRATION

Title
First Name
Last Name
Street Address
Suburb/Town
State
Country
Postcode
Email
Mobile Phone
Phone
Member Number
Medical Specialty
Medical Association Membership
Educational Institional (Students Only)
Student ID No.
Enter Special Promotion Code (if applicable)
REGISTRATION TYPE (prices incl. GST)
PACKAGE DEALS (prices incl. GST)
PAYMENT METHOD*
Please enter your Cheque No. to Identify Your Payment.
Credit Card Type (+3% Surcharge)
Credit Card Number
Credit Card Expiry (Month/Year)
3-Digit Security Code
Dietary Requirements
Please indicate if you do not wish for your details to be forwarded to:
How did your hear about this event?

PAYMENTS & CONFIRMATION

CHEQUE PAYMENTS:
Made payable to: AustralAsian Academy of Anti-Ageing Medicine Please mail to: PO Box 8244, Camberwell, VIC, AUS, 3124

Phone Payments:  +61 3 9813 0439   Fax:    +61 3 9813 0649

CONFIRMATION
A welcome e-mail will be sent to you as a confirmation of your registration.

CANCELLATION POLICY
Up to 30 days prior - 20% cancellation fee. Between 30-7 days prior - 50% cancellation fee.Up to 7 days prior - No refunds will be issued.

ACCOMMODATION
Sofitel Melbourne On Collins
25 Collins Street, Melbourne VIC 3000 Australia.
Phone: +613 9653 0000
Fax:     +613 9650 4261
W:        www.sofitelmelbourne.com.au

Conference Rate: (2011 Rate To Be Advised)
^Please note: Accomodation Rate is available between certain dates and cannot be used over any other dates than the prescribed dates above and cannot be used in conjunction with any other offer.
Hotel must be contacted directly. A5M do not take bookings for accommodation.