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Post Conference Attendee Rental List - HIMSS AsiaPac

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ATTENDEE LIST RENTAL AGREEMENT AND PAYMENT FORM<br />

ORDER NOW! Each company may order only one (1) list. Please PRINT all information except signature.<br />

This agreement is entered into and effective as of the date this Agreement is signed. The contract terms and conditions are<br />

non-negotiable and may not be changed, added to, taken away from, or modified in any way. Changes will not be accepted.<br />

The contract terms and conditions contained within this document make this a binding agreement. This Agreement is by and<br />

among the Healthcare Information and Management Systems Society ("<strong>HIMSS</strong>”) and<br />

_________________________("User").<br />

Exhibiting Company: ___________________________ Booth #: ____________<br />

Contact Person: _________________________ Tel: ____________________<br />

E-mail:_______________________________<br />

<strong>Attendee</strong> <strong>List</strong> <strong>Rental</strong> = $345 AUD*<br />

Order by 27 September 2011<br />

Use by 21 October 2011<br />

*Price is subjected to 10% GST<br />

Registrants provide demographic information on a voluntary basis.<br />

IN WITNESS WHEREOF, the parties have executed this Agreement.<br />

For USER:<br />

Company Name: _____________________________________________________________________<br />

Address: ___________________________________________________ Country: _________________<br />

City, State/Province, Country Code________________________________________________________<br />

Authorized Person (Print): _______________________________________________________________<br />

Title:________________________________________________________________________________<br />

Authorized Signature:____________________________________________ Date:__________________<br />

For <strong>HIMSS</strong> <strong>AsiaPac</strong>11: (For internal use only)<br />

<strong>HIMSS</strong><br />

Authorized Person (Print): ______________________________________________________________<br />

Title:_______________________________________________________________________________<br />

Authorized Signature:___________________________________________ Date: __________________<br />

Methods of Payment:<br />

Please charge my credit card:<br />

Visa American Express MasterCard Discover<br />

Please charge this amount $379.50 AUD<br />

Cardholder Name____________________________________________________<br />

Credit Card Number____________________________________ Exp. Date________<br />

Cardholder Signature__________________________________________________<br />

Please direct wire transfers to <strong>HIMSS</strong>:<br />

Beneficiary Bank:<br />

JPMorgan Chase Bank, Sydney Branch<br />

Beneficiary Bank Swift:<br />

CHASAU2X<br />

BSB: 212 200<br />

Beneficiary Account Name:<br />

Healthcare Information and Management Systems Society<br />

Beneficiary Account Number: 001 009 7395<br />

Please fax this form to: or Email financesupport@himss.org<br />

<strong>HIMSS</strong><br />

Attn: Finance<br />

+1 312-915-9209

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