Reconciliation SA Reconciliation Week Breakfast - Registration form

“ I’m Not Racist But..! ”
It’s time to combat racism. It’s time for recognition. It’s time for change.
Wednesday 27th May 2015, 7am to 9am, Adelaide Convention Centre, North Terrace

Get in early to secure your seat

Please complete and return this form to Reconciliation SA by Wednesday 20th May 2015,
GPO Box 11023, Adelaide, 5001 or email to . Enquiries to 08 8124 4196

Name: / Telephone:
Position:
Organisation:
Email:
Mailing address:
Postcode:
Registration Pricing details:
Individual bookings $66 pp; tables of 10 $660;
Individual Friends $55; have to be registered as a Friend of Reconciliation SA
Corporate Friends $550, table of 10; have to be registered as a Friend of Reconciliation SA
all prices are GST inclusive
Please fill in the first and last name of the person below:
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Payment details / v = vegetarian gf = gluten free
£ Please invoice as above.
£ Please make cheques payable to Reconciliation South Australia.
£ Payment has been/will be made via Direct Debit on ____/____/____.
BSB: 633-000 Account no: 148407232 Bank: Bendigo Bank Account name: Reconciliation South Australia Inc.
£ Payments by Credit Card can be made through registering on our website

£ I have read, understood and agree to Reconciliation SA’s cancellation and privacy policies.

Reconciliation SA cancellation policy:

·  Substitute participants may attend and any balance due will be paid.

·  Cancellations must be advised by email or on 08 8124 4196 prior to the 20th May otherwise a $10 administration fee is payable.

·  Cancellations received on or after 20th May will not be refunded.

·  Seats booked but left vacant will result in any outstanding fee being charged.

Reconciliation SA privacy policy: Reconciliation SA is committed to protecting the privacy of information collected for its internal use only about any persons or organisations. Personal information is not shared, sold, rented, traded or otherwise supplied to other third parties.