TAX INVOICEABN: 54 004 553 806

Please carefully read through all the information before fi lling in the registration form. Please type or print in block letters and keep a photocopy for your records. Each registrant must complete a separate form.

All prices are quoted in Australian dollars and include GST. Tax invoices will be issued to all registrants following receipt of the registration form.

HOW TO REGISTER

Register online at www.mm2010shpa.com OR Complete the registration form and forward to:

Conference LogisticsPO Box 6150 Kingston ACT 2604Phone: 02 6281 6624 Fax: 02 6285 1336

PLEASE INDICATE YOUR LEVEL OF SPONSORSHIP:

Major Standard Other

SECTION A: DELEGATE Mr Mrs Ms Miss Dr Professor Other (Please specify):

First Name: Last Name:

Preferred Name for Badge:

Organisation:

Position:

Address:

Suburb/Town: State: Postcode:

Country:

Telephone: ( ) Facsimile: ( ) Mobile:

Email:

Special Requirements (eg dietary, disability)

SHPA Membership number:

PRIVACYA list of delegates will be supplied to all registered attendees and sponsors at the Conference. The list will contain delegates’ name, organisation, state and email address. Please indicate below if you do not agree to have your details included.

Please DO NOT include my details in the delegate list

SPONSOR REGISTRATION FORMSPONSOR REGISTRATION FORM

Please refer to your sponsorship entitlements before completing sections B-F

SECTION B: SPONSOR REGISTRATION FEES

REGISTRATION TYPE

Sponsor Registration – Complimentary $0

Sponsor Registration – Additional Staff Member $370

Total Payment: Section B: $

SECTION C: CONCURRENT SESSION INDICATORSponsor delegates are welcome to attend all scientifi c sessions.To assist with room allocations, please indicate your fi rst preference

Friday 12 November 1330-1500 S1 S2 S3 S4 S5Saturday 13 November 0900-1030 S6 S7 S8 S9 S10

SECTION D: ADDITIONAL MEETINGS/SEMINARS

Early bird FeeBefore 3 September

2010Standard Fee

After 3 September 2010

THURSDAY 11 NOVEMBER

Paediatric COSPSHPA MemberNon-member

$130 $200

$160 $230

Medication Safety COSPSHPA MemberNon-member

$130 $200

$160 $230

Academic Detailing COSPSHPA MemberNon-member

$80 $130

$110 $150

Clinical Pharmacy COSPSHPA MemberNon-member

$80 $130

$110 $150

Oncology COSPSHPA MemberNon-member

$80 $130

$110 $150

Mental Health COSPSHPA MemberNon-member

$80 $130

$110 $150

SUNDAY 14 NOVEMBER

SHPA Leadership ProgramSHPA member who holds a position on SHPA Branch Committees, Committees of Specialty Practice, Reference Groups or other offi cial SHPAWorking groups/committees

Please state your position

Other Members $0 $60

Total Payment: Section D $

SECTION E: BREAKFAST SESSIONSPlease refer to your sponsorship entitlements to determine if the Saturday Breakfast is included.For catering, purposes please indicate if you will be attending:

Function I Will be Attending

Breakfast with the BGsConference DelegateNon-conference Delegate

Yes No $60

Critical Care COSPConference DelegateNon-conference Delegate

Yes No $60

Medicines Information COSPConference DelegateNon-conference Delegate

Yes No $60

Rural Network BreakfastConference DelegateNon-conference Delegate

Yes No $60

Technician Network BreakfastConference DelegateNon-conference Delegate

Yes No $60

Total Payment: Section E $

SECTION F: SOCIAL FUNCTIONSPlease refer to your sponsorship entitlements to determine if your registration includes admittance to these functions.

For catering purposes, please indicate if you will be attending:

Function Details I Will be Attending

Wine and NibblesThursday 11 November

Melbourne Convention Exhibition Centre1730-1830 Yes No

SHPA AGMThursday 11 November

Melbourne Convention Exhibition Centre1830-1900 Yes No

Welcome ReceptionFriday 12 November

Melbourne Convention Exhibition Centre1730-1930 Yes No

Gala DinnerSaturday 13 November

Melbourne Convention Exhibition Centre1900 until late Yes No

SECTION G: ADDITIONAL SOCIAL FUNCTION TICKETSAdditional tickets for people wishing to attend any of the social events can be purchased by completing this section

Function Details Number of Tickets/Cost

Wine and NibblesThursday 11 November

Melbourne Convention Exhibition Centre1730-1830 ______ x $45

Welcome ReceptionFriday 12 November

Melbourne Convention Exhibition Centre1730-1930 ______ x $65

Gala DinnerSaturday 13 November

Melbourne Convention Exhibition Centre1900 until late _____ x $150

Total Payment: Section F $

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SECTION H: ACCOMMODATIONOne night’s deposit must be made or credit card details given at time of booking to guarantee your reservation.Please see the conference website for full booking conditions and payment requirements.Please indicate your preferred payment option:

Credit card guarantee One night’s deposit Full prepayment

Arrival Date: _____/_____/____ ETA __________

Departure Date: _____/_____/____ ETD __________

Type of Room: Single Double Twin

For twin share, I will be sharing with _________________________________________________________________

Hotel Room Type Rate (per room per night) Preference

Hilton Melbourne South Wharf Guest Room $255

Crown Promenade Hotel Standard Room $245

Quest Apartments Southbank One Bedroom ApartmentTwo Bedroom Apartment

$188$257

Novotel Standard Queen $199

Vibe Savoy Hotel Melbourne Standard Room $199

Quality Hotel Batman’s Hill Standard RoomClub Room

$140$176

Rendezvous Hotel Deluxe Queen $189

Travelodge Southbank Standard Room $140

Hotel Enterprize Classic Courtyard Room $120

Total Payment: Section G $

PAYMENT SUMMARY

Section B Conference Registration $

Section D Additional Meetings/Seminars $

Section E Breakfast Sessions $

Section G Additional Social Function Tickets $

Section H Accommodation $

TOTAL AMOUNT DUE: $

METHOD OF PAYMENTCheque/Money OrderA. Must be made out to Medicines Management

Electronic Funds TransferB. Please quote delegate’s surname or invoice number as EFT reference and forward a copy of your remittance advice to 02 6285 1336 or email conference@conlog.com.au

Credit CardC. Please note that Conference Logistics will appear on your statement

MasterCard Visa Total Amount: $______________

Cardholder’s Name:__________________________________

Card Number:

Signature: Expiry Date: __ __ / __ __ / __ __

In signing I acknowledge the registration information is true and correct and I have read, understand and agree to the terms and conditions as outlined in the registration brochure and on the conference website.

Signature: ______________________________________________________________________________________

Name: ______________________________________________________________________ Date: ___ /____ /____