Professional Day 12th May 2017
A Voice to Lead
Australian Nursing and Midwifery Federation NT Branch
Professional Day – A Voice to Lead
12th May 2017
Grand Ballroom Skycity Darwin
ANMFNT Members/Non-Member Registration Form
Send completed form to: Admin Officer ANMF NT Branch PO Box 42533 CASUARINA NT 0810 or
Email: [email protected] or Fax: 8985 5930
Your Details
Family Name: ______________________________ _________Given Name: ____________________________________________
Address: ________________________________________________________________________________P/Code____________
Workplace: ____________________________________
Contact Details:
Work Ph No: ________________________________ Home Ph No: ___________________________________________________
Mobile: _________________________________________ Fax No: ___________________________________________________
Email Address: _____________________________________________________________________________________________
Special Requirements:
Please advise if you have any special requirements; for example, dietary or mobility:
__________________________________________________________________________________________________________
Registration Selection
Professional Day Details:
Venue: Sky City Casino – Grand Ball Room
Date: Friday 12th May 2017
Time: 9.00am – 5.00pm
ANMFNT Members Early Bird: $80.00 before the 17th March 2017 ($60.00 with $20.00 reimbursement for ANMFNT Members
Only)
ANMFNT Members Early Bird: $90.00 before the 7th April 2017 ($70.00 with $20.00 reimbursement for ANMFNT Members Only)
ANMFNT Members Full Registration: $100.00 (after the 7th April 2017)
Non-Members: $150.00
Morning tea, Lunch and Afternoon tea provided.
Payment
Professional Day 12/05/2017
ANMFNT Members - ($80.00/$90.00/$100.00) $________________
Non Members - $150.00
□ Cheque (made payable to ANMF NT Branch)
□ Direct Debit – BSB 065901, ACC 00900930
Reference Surname & member No ( Last 4 digits)
□ Credit Card
Card Type: Visa □
MasterCard □
Card Number _ _ _ _/ _ _ _ _ / _ _ _ _ /_ _ _ _
Exp Date: ___/___
Name of cardholder:_____________________________Signature_____________________________