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Personal Details *<br />

Title _________ Given Name _________________________ Family Name ______________________________________________________<br />

Position ___________________________________________ Department ______________________________________________________<br />

Organisation _______________________________________________________________________________________________________<br />

Mailing Address * ____________________________________________________________________________________________________<br />

____________________________________________________ Country * ______________________________________________________<br />

Email *______________________________________________Phone Number Country Code (+_____ ) Area code ( ___ ) __________________________<br />

Mobile/Cell Number Country Code (+_____ )______________________Fax Number Country Code (+_____ ) Area code ( ___ ) __________________________<br />

Special Requirements eg. Vegetarian, Wheelchair access _____________________________________________________________________<br />

* Required fi eld † If an alternate email address is specifi ed, all email correspondance will be sent to both addresses.<br />

Registration Fees<br />

7-8 July 2011 Park Hyatt Melbourne<br />

Full Delegate Registration - FAPM Member @ $1199 (inc GST) _______________________<br />

Full Delegate Registration - Non-Member @ $1699 (inc GST) _______________________<br />

Full Delegate Registration - Government & Teaching Institutions @ $1500 (inc GST) _______________________<br />

Registration Fees Subtotal $ ________________________<br />

Social Program<br />

Payment Details<br />

Welcome Reception<br />

All Payments must be made in Australian Dollars only.<br />

Date: Thursday, 7 July 2011<br />

Time: 17:30–19:30<br />

Venue: Trilogy Room, Park Hyatt Melbourne<br />

Dress: Smart Casual<br />

Included in registration fee.<br />

Note that payment by credit card is mandatory for registration<br />

online. Cheque or overseas bank drafts are not permitted for<br />

electronic submission. Charges will appear as ICMS Pty Ltd on<br />

your credit card statement.<br />

Please indicate attendance: Attending Not Attending<br />

Amount Due $___________<br />

Additional tickets ________ x @ $90 (inc GST) $___________<br />

Conference Gala Dinner<br />

Card Type Mastercard Visa American Express<br />

Date: Friday, 8 July 2011<br />

Pre-dinner drinks: 18:15–19:15<br />

Cardholder’s Name__________________________________<br />

Sit down Dinner: 19:15–23:30<br />

Venue: Park Hyatt Melbourne<br />

Card Number_______________________________________<br />

Dress: Business Attire<br />

Included in registration fee.<br />

Expiry Date _ _ /_ _ Month / Year<br />

Please indicate attendance: Attending Not Attending<br />

Signature__________________________________________<br />

Additional tickets ________ x @ $150 (inc GST) $____________ Note to Conference Offi ce<br />

Post-Conference AFL Function - Essendon VS Richmond<br />

Date: Saturday, 9 July 2011<br />

If you have any special comments for the Conference Offi ce<br />

please write a short note here.<br />

Time:<br />

Venue:<br />

17:30–23:00<br />

Hilton on the Park for pre-game dinner;<br />

Note_____________________________________________<br />

Included:<br />

Melbourne Cricket Ground (MCG) for the game<br />

Pre-game dinner (including drinks) and reserved seat at the _________________________________________________<br />

Meeting point:<br />

game. Food and drink at the MCG is not included.<br />

Hilton on the Park foyer<br />

_________________________________________________<br />

Tickets ________ x @ $140 (inc GST) $___________ _________________________________________________<br />

Social Program Subtotal $___________ _________________________________________________<br />

Cancellations and Refunds<br />

Cancellations must be advised in writing<br />

to the Conference Offi ce. Cancellations<br />

received prior to Thursday, 26<br />

May 2011 will receive a refund of<br />

registration fees less an administration<br />

charge of $250.00. Cancellations after<br />

this date will not be refunded.<br />

Privacy Policy<br />

In registering for this conference, relevant details will be incorporated into a participant list for<br />

the benefi t of all delegates (name and organisation only). Details may be made available to parties<br />

directly related to the conference including venue providers (for the purpose of room bookings<br />

and conference options), key sponsors (subject to strict conditions) and to inform you via email of<br />

future FAPM conferences. Please tick the box below if you do not wish to have your name included<br />

in the participant list.<br />

I do not consent<br />

Fax/email the completed form to +61 3 9682 0288 or fapm2011@icms.com.au.<br />

For phone enquires please call +61 3 9682 0244 or visit the website www.fapm2011.com

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