Australian School of Medical Imaging

ASMI Seminar Registration Form

Seminar Details

Seminar Code

Seminar Name

Seminar Date

Seminar Cost

Personal Details

Surname

First Given Name

Title (Prof/Dr/Mr/Mrs)

Position

Employer

    

Special Dietary
Requirements

Preferred Contact Details

Private Phone

Business Phone

Mobile Phone

Email

Postal Address

Po Box

OR

Building address/
Street Number
Suburb

State

Postcode
Country

Method of Payment

All fees are due 14 days prior to the seminar start date. To secure your position in the seminar a 10% deposit is payable on Registration. A cancellation fee of 10% will be incurred if your attendance is cancelled by you less than 30 days prior to the seminar start date.

Credit Card (This page will be sent to PayPal)

Invoice to (We will send you invoice by post)

Invoice to

Self at postal
address above

 Yes

OR

Name / Title

Department
Company /
Organisation
Address