Nozawa Onsen Registration Form

21st January 2018 - 27th January 2018

Enrolment numbers are limited so we advise that your travel and accommodation arrangements should not be booked before you receive confirmation of your registration from the conference secretariat. Registration and extra tickets must be paid in full before you commence your accommodation bookings. 


Payment Options:

There are three payment options 

1.    Cheque 
2.    Electronic Funds Transfer
3.    PayPal

Cheques
To be made payable to ‘Medicine with Altitude’ and sent to the address below as soon as you submit this form: 

Medicine with Altitude
665 Moobi Road
SCONE NSW 2337 AUSTRALIA.

Electronic Funds Transfer
To be transferred as soon as you submit this form.

Medicine with Altitude Bank details:

Virtual Gypsies
Commonwealth Bank of Australia
BSB:062-598
A/C: 1010 7400

(with your reference: Noz & your last name & first initial of first name)

PayPal
Follow instructions after you submit this form.

  *-Required

REGISTRATION:

Delegate Registration Fee includes all CME sessions and event functions
Delegate = $1695: *

Extra Tickets for Accompanying Adults

Welcome Reception

Adults - $40 AUD each:
Under 12 years - $20 AUD each:

Apres Ski Drinks

4 Nights - $100:

Conference Dinner

Adults - $90 AUD each:
Under 12 years $50 AUD each:
Total: *
Please note, cancellations made up to 90 days prior to the conference will
receive a full refund less a $190 administration fee. However cancellations
made less than 90 days prior to the conference will be non-refundable.
I agree to the above terms and conditions: Yes *

Payment Method: Crossed Cheque
PayPal
Electronic Transfer
*

Delegate Details

Title: *
Last Name: *
First Name: *
RACGP Number:
ACRRM Number:
ACEM Number::
Date of Birth:
Street Address: *
Town/City: *
State: *
Postcode: *
Country: *
Mobile: *
Email: *

Specialty:
Potential Speaker: Yes
Verification:
*