Advanced Course Application Form 2010

TPDN Level 2 Courses

Please complete your details below.

You may make a deposit payment to secure your place in the course, with the balance due one month prior to course commencement. You will receive seperate notification with payment options when final payment is due. You may also make full payment now.

After payment, you will be emailed a receipt, along with a download link for important pre-course information. You must also sign and return the consent/waiver prior to the course, along with your treatment diary.

Please register me for the following event:

	Hawaii - *	(Hawaii)	TBA
	Christchurch - NZ	(Canterbury Uni)	23rd - 24th March, 2010
	Melbourne - VIC	( Milano's Brighton)	23rd - 24th April, 2010
	Sydney - NSW	(APA Head Office)	18th - 19th May, 2010
	Auckland - NZ	(AUT)	21st - 22nd September, 2010
	Melbourne - VIC	( Milano's Brighton)	29th - 31st October, 2010
	Please send me information on accommodation

 

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	Standard Fee: AUD$890.00		NZPA/APA Members: AUD$850.00
	I want to only pay the deposit amount of $200.00
All fees in Australian Dollars and include GST

Name*:			Health Care Discipline:	< Select One > Physio Chiro Osteo GP Sports Physician Podiatrist
Address*:
Address 2:
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How did you hear about us?* < Select One > In Motion APA Journal NZPA magazine Colleague who has previously attended Google search Website AOA flyer AOA magazine CAA flyer CAA advertising Physiofocus - NZ Physio Matters - NZ   Other:
Special Dietary Requirements?

 

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Payment Method

 

Please accept my payment for AUD$, paid via: Cheque Please make cheque payable to GEMt Pty Ltd Electronic Funds Transfer Electronic Funds Transfer to GEMt Pty Ltd ANZ Bank BSB: 013304, Account: 486808383 Credit Card Card Type VISA Mastercard Card Number: Expiry Date: January February March April May June July August September October November December  /  2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 CCV: (what is this?) Cardholder Name:

 

Mail to:	Fax to:	Phone Registration:
Attention: Deb Hampton GEMt Pty Ltd 150 Tulip St Sandringham VIC 3191	(613) 9583 0611	(613) 9583 5248

 

 

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