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ICOM
INTERNATIONAL COMMITTEE ON MANAGEMENT
COMITÉ INTERNATIONAL POUR LA GESTION
CONFERENCE 2003 - CANBERRA, AUSTRALIA
CONFERENCE BOOKING FORM
Please complete a separate form for each delegate even if registering multiple delegates from the same organization. Please return completed form(s) to Conference Logistics, INTERCOM Conference 2003, PO Box 201, Deakin West, ACT, 2600, AUSTRALIA or fax to:+61 2 6285 1336 by 7 November 2003. For queries, please email conference@conlog.com.au
PERSONAL DETAILS
Family Name................................................ Title............................... First name...................................
Organisation..........................................................................................................................................
Position.................................................................................................................................................
Address.................................................................................................................................................
Suburb/City....................................................... State.................................... Postcode.........................
Country.................................................................................................................................................
Phone...............................................................Fax..............................................................................
Email....................................................................................................................................................
Preferred name for name badge...............................................................................................................
Special requirements (e.g. dietary, disability)............................................................................................
REGISTRATION (All fees are inclusive of GST)
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Conference Registration (19 & 20 November) (ICOM Member) |
AUD $200 |
$ _ _ _ _ |
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Conference Registration (19 & 20 November) (non ICOM Member) |
AUD $250 |
$ _ _ _ _ |
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Optional Pre Conference Site Visit in Sydney -17 November*
(Visit to National Maritime Museum and Powerhouse Museum) |
AUD $25 |
$ _ _ _ _ |
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Optional Post Conference Site Visit in Melbourne -21 November*
(Visit to Museum of Victoria and Federation Square) |
AUD $25 |
$ _ _ _ _ |
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*A minimum of 20 participants per site visit is required for the visit to go ahead |
TOTAL
| $ _ _ _ _ |
PAYMENT DETAILS
__ I wish to pay by credit card and hereby authorize you to charge the amount of AUD $ _ _ _ _
to my credit card
Type of card: __ Mastercard __ Bankcard __ Visa __ AMEX __ Diner's Card
Name on the card: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiry date: _ _ / _ _
Credit card number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ I enclose bank draft for AUD $ _ _ _ _ drawn on an Australian Bank, payable to Intercom Conference 2003
__ I am faxing registration form and bank draft will follow.
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