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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