Registration Form / Tax Invoice

ABN: 48146970005
Please register me for ADHD Conference:
Name:______________________________________Position_________________________
Address:____________________________________________________________________
Phone Contact_______________________________________________________________
Email:______________________________________________________________________
Dietary Requirements:_________________________________________________________
Concurrent Sessions:
1
2
3
4
st
nd
Please circle your 1 and 2 preference. First come first service.
Date: 2nd August 2013 [Friday]
Time: 0800 to 16.30pm
Venue: Castle Hill RSL Club, 77 Castle Street, Castle Hill NSW 2154
Cost: $115.00 GST Inclusive. Catering included. No refund will be given but you can
nominate another person to replace your attendance.
Registration: Closing date 26th July 2013
___________________________________________________________________________
Nominate payment methods:
1. Cheque payable to The Delta Clinic Pty. Ltd.
2. Direct Debit: BSB: 082155 / Account No: 184304964
3. Credit Card: Please debit MasterCard / Visa

Reference: ADHD Conf.

[Please print]

Card Number:__________________________________ExpiryDate:_____/______CCV*____
Name on card__________________________________Signature______________________

Enquiries: David Hong, Director, The Delta Clinic

Office: 02 98991518
Fax form: 02 96595834
Email: thedeltaclinic@gmail.com
Website: thedeltaclinic.com.au
Post form to PO BOX 6952 Baulkham Hills NSW 2153