ON-LINE REGISTRATION FORM
Use tab or mouse to move around the form - do not use ENTER ! |
| Identification |
* - required field |
| *Title (Mr, Mrs, Miss, Ms, Dr etc) |
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| *First Name: |
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| *Family Name: |
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| *Organisation/Company: |
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| * Postal Address ... Box/Street: |
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... Suburb: |
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*... City: |
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*... Postcode: |
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| *Telephone: |
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| Fax: |
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| *Email: |
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| *Please re-enter email as a check: |
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| Special needs (dietary, mobility etc): |
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| Privacy |
Information will be published in the conference documentation. If you do not want your details published please tick here
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| Status. I am a: |
*(select one) |
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| Conference Attendance |
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| I will attend ... |
| *Welcome Function, Wed 1 Sep 5 – 7 pm (included in fee) |
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| *Conference Dinner, Thu 2 Sep 7.30 pm (Optional extra $80 incl GST) |
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| * AGM (incl breakfast), Fri 3 Sep 7am (Note: Members only) |
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* The Concurrent Session on:
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Please see page 5 of the downloadable brochure for details of concurrent sessions (brochure opens in new window)
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| Travel to and from airport |
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Arrival
Date
Flight No
Arrival Time
Book Transfer
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Departure
Date
Flight No
Departure Time
Book Transfer
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| Accommodation |
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| Holiday Inn Auckland Airport (Studio Rooms @ $155 incl GST per night: |
select one |
| The Hotel is a non-smoking venue and heavy penalties may occur if you smoke in the rooms |
| I plan to arrive on: |
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| I shall depart on: |
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| I shall be sharing with: |
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Fees
All fees are in $NZ and include GST @12.5%
Form becomes a GST Invoice on completion. GST number 60–818-193 NZHHA |
| *Registration Fee: |
select one |
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| Post-Conference Activity |
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| Please see pages 7 & 8 of the downloadable brochure for details of post-conference activities (brochure opens in new window) |
To book a place please indicate below. Note the number of places you are booking and names of participants. Invoice will be sent separately following confirmation of activity. |
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| Payment |
Must be received by date of Fee Close Off (Early Bird 15 July, Standard 15 Aug, Late after 16 August) |
| Please send tax invoice
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| Please indicate payment method: |
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CHEQUE Make Cheques out to NZ Home Health Association Conference and send with copy of this form to Conference Brokers |
DIRECT CREDIT Email Advice note to conferencebrokers@xtra.co.nz giving name, organisation date and amount paid. Account details: Westpac Bank, Molesworth St, Wellington ... NZHHA Conference 030518 0301246 02 |
CREDIT CARD
On submission of this form you will be passed to our secure server to process your credit card payment.
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201006233 |
