RegistrationForm/Tax Invoice

This document is a TAX INVOICE upon completion of the form and when payment is made.

Please retain a copy for taxation purpose when making full payment for the GST inclusive amount.

Please sign & date below *. Individual forms must be completed for each attendee.

Falls and Cognitive Impairment

½ day Workshop (Thursday 6th February, 12.30pm – 4.30pm)

$240(incl. GST) per person or $20 discount p/person applies for multiple registrations from the same organisation

Participant Name:______Title: ______

Organisation:______

Position in organisation:______

Is your organisation a:  Residential Care Facility OR  Community Facility/Service (Please tick)

Organisation address:______

______Postcode ______

Contact Telephone:______Fax: ______Mobile: ______

Print Email address:______

Special Dietary requirements:______

*Registrant’s Signature:______Date:______

Payment must be received prior to the workshop/seminar to secure registration and placement

TOTAL AMOUNT: AU$______(Total Includes GST)

 Electronic Funds Transfer (EFT) payable to the National Ageing Research Institute Ltd

BSB no: 083-170 Account no: 136 549 422Payment Reference(registrant’s name + workshop ref: E131031 Falls)

Visa Mastercard Other (please specify) ______

Card holder’s name: ______Signature: ______Expiry date: __ __ / __ __

Cheque payable to the National Ageing Research Institute Ltd. ABN: 71 154 866 047

Cancellation policy:

Registration must be paid prior to the workshop commencement and is not refundable. A full refund, will be given if a workshop is cancelled. Registrations within a workshop are transferrable to a colleague. A credit may be redeemable at the next available workshop with prior notice not less than 48 hours, if agreed to by NARI.

Email to:or fax: 03 9387 4030. (Registration confirmed by email).

National Ageing Research Institute Ltd

Gate 4, 34 – 54 Poplar Road, Parkville, Victoria 3052 Australia. PO Box 2127 Royal Melbourne Hospital, Victoria 3050

T61 3 8387 2305 F61 3 9387 4030 E Director Professor David Ames

ABN 71154866047 ACN 154 866 047. Affiliated with The University of Melbourne and Melbourne Health