Please print and fax this form to 03 8317 0444

Title:_____First Name:__________________ Family Name:______________________

Address:_______________________________________________________________

Phone:___________________Email:_________________________________________

Dietary Requirements:_____________________________________________________

Payment: Cheque (Made payable to Corporate and Personal Consulting Pty Ltd, sent to 310/2 Queen Street, Melbourne, 3000)

Credit Card (VISA or Mastercard)

Name on Card___________________________________Expiry Date: ______/________

Card Number:     Amount:__________________


Signature_______________________________________________________________

For more information, please contact:
Dr Simon Kinsella – 8317 0444.