ALFRED HEALTH

Allergy & Asthma Consultants

ABN: 27 318 956 319

2015 Course Registration Form & Tax Invoice

PLEURAL ULTRASOUND COURSE
Venue:

AMREP Centre
Alfred Hospital
55 Commercial Road
MELBOURNE VIC 3004

Date:

Friday 6th November 2015

Fee:

$660.00 ($600.00 PLUS $60.00 GST)

Name_________________________________ Organisation_________________________________

Address for Correspondence__________________________________________________________

Daytime Telephone No______________________ Fax No__________________________________
Email Address (please write clearly)___________________________________________________
Dietary Requirements (if required)___________________________________________________
Credit Card Payment details
Please arrange to debit $660.00 to:
Mastercard

Visa

Card No _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _

Valid to_ _/_ _

3 digit security code (on reverse of card) _ _ _

Please forward completed registration form & payment to:

Maria Mastorakis, AIRMed
C/- The Alfred
PO Box 315
Prahran VIC 3181
Contact:
Maria Mastorakis
Tel: (03) 9076 2934 Fax: (03) 9076 2245
Email: m.mastorakis@alfred.org.au
Refunds and Cancellations
I understand that payment of the course fee is non-refundable, except in the unlikely event the course is
cancelled in which case a full refund would be provided.