Ticket Purchase Order Form

2014 PREMIER’S GALA DINNER

TICKET PURCHASE ORDER FORM

Saturday 15 March 2014

Palladium Ballroom, Crown Entertainment Complex, Melbourne - 7.00pm for 7.30pm start (sharp)

Join us for a spectacular evening celebrating Victoria’s cultural diversity. Enjoy a dynamic program of entertainment , a delicious three-course dinner, and wonderful networking opportunities.

Ticket order:

Please indicate the number of tickets required in the appropriate box/es below:

Subsidised tickets
(subsidised tickets for voluntary community organisations only) / Full priced tickets
(tickets for Government, service providers, business and corporate organisations)
x individual tickets ($70 each) / x individual tickets ($160 each)
x table of 10 people ($700) / x table of 10 people ($1600)
x table of 11 people ($770) / x table of 11 people ($1760)
x table of 12 people ($840) / x table of 12 people ($1920)
Subtotal $...... / Subtotal $......
Total amount payable $......

TICKETS ARE LIMITED TO A MAXIMUM OF TWENTY-FOUR (24) TICKETS PER ORGANISATION.

Please note:

Demand for tickets to this event is traditionally very high. Please ensure you return this form and your payment promptly to allow the best opportunity to secure seats. If your request for tickets is unsuccessful you will be notified, and your payment will be returned.

Please complete both pages of this form and return it with your payment as soon as possible, but no later than Friday 31 January 2014, for an opportunity to be allocated tickets.

If successful, tickets will be sent via Australia Post registered mail in February.

For refunds to be provided, cancellations must be receivedby no later than Friday 14 February 2014.

For enquiries please contact Dana Di Giovanni on (03) 9651 0647 or

PLEASE ENSURE YOU ENCLOSE PAYMENT DETAILS WITH THIS FORM: TICKETS WILL NOT BE ALLOCATED IF PAYMENT IS NOT RECEIVED.

Dietary and special requirements:

Please advise of any dietary or other special requirements:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

THIS PAGE WILL BECOME A TAX INvoice UPON RECEIPT OF PAYMENT.

PLEASE KEEP A COPY FOR YOUR RECORDS.

ABN 90 795 126 275

Send completed form & payment details to:

Victorian Multicultural CommissionOR

Attn: Dana Di Giovanni

GPO BOX 4698

Melbourne

VIC 3001

Name of Organisation: …………………………………………………………………………

Name of Contact Person:…….………………………………………………………………

ABN:…………………………………………………………………………………………

Address: ……………………………….………………………………………………………

……………………………………………… Postcode: ……………………….………….

Telephone: ……………………………… Mobile: ……………………………………

Email: …………………………………………………………

Number of tickets requested: …………………………. (Maximum of 24 tickets per organisation)

Please tick the relevant box to indicate your payment type:

Payment by Cheque - Payment Amount $ ……………………….

Please make cheque payable to: DEPARTMENT OF PREMIER AND CABINET

Payment by Credit card – Payment Amount $......

Bankcard Visa Card MasterCard

Card Holder’s Name:……………………………………………………………

Card Number:

Expiry Date: ………….…/………………… CVN Number: …………………………………

Payment Amount: $…………………………..

Signature: …………………………………………Date: ….../……./………