The ADA NSW Convention - Institute for Dental Implants

Don’t like filling out forms? Register online at www.adansw.com.au/convention
REGISTRATION FORM
DELEGATE DETAILS
Title: First Name: Surname
Organisation/Practice:
Postal address: Suburb/Town: State: Postcode:
Phone: Fax: Mobile:
Email
Special Dietary Requests:
REGISTRATION FEES
Full Convention Registration Fee INC GST
Includes access to convention sessions, morning and afternoon tea, lunch, welcome reception, gala dinner, satchel, industry exhibition entry and Saturday breakfast session
Category
Early Bird Rate
(by 31 July 2012)
Standard Registration
(from 1 August 2012)
Dentist – ADA Member Membership No.: $1350 $1650
Dentist – Non Member $1450 $1750
Dentist Assistant – NSW DAA Member NSW DAA Membership No.: $495 $495
Dental Assistant – Non NSW DAA Member $495 $550
Dental Auxiliary employed by ADA Member Employer’s ADA Membership No.: $1000 $1000
Dental Auxiliary not employed by ADA Member $1350 $1650
Corporate/Technician/Prosthetist $1750 $1750
Complimentary Functions INC GST
Pleases indicate if you will be attending these functions (1 x tickets is included in the Full Convention Registration fee, however RSVP is required for catering purposes).
Date Function Yes, I will be attending No, I will not be attending
Thursday, 13 September 2012
Saturday, 15 September 2012
Saturday, 15 September 2012
Welcome Reception: 6:00pm – 8:00pm
Breakfast Session: 7:30am – 8:45am
Convention Gala Dinner: 6:30pm for 7:00pm Dinner
One Day Registration INC GST
Includes access to convention sessions, morning and afternoon tea, lunch and industry exhibition for one day only. Does not include access to welcome reception, gala
dinner or Saturday breakfast session. Tickets for these events can be purchased separately in the Additional Functions section.
Category Fri, 14 Sept 2012 Sat, 15 Sept 2012
Dentist – ADA Member Membership No.: $750 $750
Dentist – Non Member $875 $875
Dentist Assistant – NSW DAA Member NSW DAA Membership No.: $250 $250
Dental Assistant – Non NSW DAA Member $275 $275
Dental Auxiliary employed by ADA Member Employer’s ADA Membership No.: $500 $500
Dental Auxiliary not employed by ADA Member $825 $825
Corporate/Technician/Prosthetist $875 $875
Additional Functions INC GST
One (1) ticket for each of these functions is included in the Full Convention Registration Fee. Additional tickets may be purchased for guests/partners, or One Day registration.
Date Function Cost (inc GST) Name/s of attendee
Thursday, 13 September 2012 Welcome Reception: 6:00pm – 8:00pm _______ x tickets at $95
Saturday, 15 September 2012 Breakfast Session: 7:30am – 8:45am _______ x tickets at $75
Saturday, 15 September 2012 Convention Gala Dinner: 6:30pm for 7:00pm Dinner _______ x tickets at $225
TOTAL $
PAYMENT DETAILS
A cheque payable to ADA NSW Centre for Professional Development
Please charge the total amount to the following credit card: Visa Mastercard American Express
Card Number Security Code (on back of card/front on AMEX) Expiry Date
Cardholder Name
Cardholder Signature