AVT

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23rd - 27th March 2010

Adelaide

Vascular

Trials

Registration

Accommodation

REGISTRATION FORM / TAX INVOICE

Last Name:

First Name:

Institution:

Address:

State:

Post code:

Phone (Work):

Mobile:

Fax:

Email:

Please tick if you do not wish to release your details to the Industry sponsors

*** For general catering purposes, if Vegetarian or allergic to specific foods, please state:

REGISTRATION DETAILS

Withdrawals from the course will be fully refunded if advice received prior to 6th March 2010. Following this date, a refund of 75% of course fee will be made.

Registration Fee(Final year trainee)

$2428 (inc GST)

Registration Fee (Early year trainee)

$1339 (inc GST)

Number attending course dinner on 27th March 2010

ACCOMMODATION

To secure your accommodation reservation, please contact laurenh@pht.com.au directly, quote “Adelaide Vascular Trials” and provide credit card details. A deposit of one night’s accommodation will be requested to secure your booking. A special rate has been secured for the AVT during the period of the course. All accommodation is subject to availability at the time of booking.

Holiday Inn 65 Hindley Street ADELAIDE

Majestic Hotel 55 Frome Street ADELAIDE

Pacific International Suites 55-67 Hindmarsh Square ADELAIDE

Sebel Playford 120 North Terrace ADELAIDE

None Required

Arrival Date

Departure Date