10. Member. Non-member. Total attendees: Total amount: $. Payment details: Credit card: Visa. Mastercard. AMEX Amount: $
BOOKING FORM Date Friday 16 June 2017
Time 6.30pm – 11pm
Venue Marquee, Victoria Park Golf Club, 309 Herston Road, Herston
Cost AMA Queensland members $125 Non-members $155 Group booking (table of ten) $1,200
Attendee details:
Name: Dr / Mr / Ms / Mrs / Miss Member number:
Member
Non-member
Organisation:
Office Phone:
Mobile:
Email:
Postal address:
Dietary requirements:
Additional attendees and group bookings:
Please complete the table below with the names of all guests on your table. Name
Member / Non-member
1.
Member
Non-member
2.
Member
Non-member
3.
Member
Non-member
4.
Member
Non-member
5.
Member
Non-member
6.
Member
Non-member
7.
Member
Non-member
8.
Member
Non-member
9.
Member
Non-member
10.
Member
Non-member
Total attendees:
Dietary requirements
Total amount: $
Payment details: Credit card:
Visa
Mastercard
AMEX
Amount: $
Card number:
Expiry date:
Cardholder’s name:
/
CCV:
Signature:
Direct deposit: Contact the Events Team on (07) 3872 2222.
Submit booking form
Email:
[email protected] Fax:
(07) 3856 4727
Mail:
PO Box 123, Red Hill QLD 4059
For any enquiries, please contact the Events Team on (07) 3872 2222.
Preferred Medical Indemnity Provider
PRIVACY INFORMATION: AMA Queensland’s primary purpose of collecting personal information on this form is to process your purchase. In providing your details you consent to your personal details being used in the manner indicated. ABN: 17 009 660 280
