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QUALITY COUNTS
“QUALITY COUNTS” REGISTRATIONNew Zealand Institute of Medical Radiation Technology
NZIMRT Conference August 17-18th 2012Crowne Plaza Hotel, Albert Street, Auckland
Registrant Details:
Dr/Mr/Mrs/Miss/Ms _________________________________________________________________________________
First Name Surname
Radiation Therapy Diagnostic Imaging Education Other __________________________________
Name for Name Badge: ____________________________________ NZIMRT/AIR membership No: ______________
Employer: ______________________________ Location: __________________________________________________
Postal Address: _____________________________________________________________________________________
City/Town: _________________________________Post Code__________ Country: ____________________________
Telephone (Daytime): ______________________________ Mobile: __________________________________________
E-mail address: _____________________________________________________________________________________
Please indicate how you would like to receive confirmation of your registration Mail / E-mail
Special requirements: (Dietary, mobility etc) Please advise details of specific dietary requirements as necessary
____________________________________________________________________________________________________
Registration Details: (Please circle to indicate your selection) All fees are in $ NZ and include 15.0 % GST
Early-Bird Registration(Before 13/07/12)
Late Registration(After 13/07/2012)
No. Fee Due
Member Non-Member Student (no Awards dinner)
Member Non-Member Student
Full Registration $450.00 $600.00 $160.00 $675.00 $900.00 $180.00
Friday Only $235.00 $385.00 $ 90.00 $352.00 $577.00 $135.00
Saturday Only $235.00 $385.00 $ 90.00 $352.00 $577.00 $135.00
Please indicate if you would like to attend the gala dinner and Awards Function on Friday Night(*this is included in the full registration price only (not student or one day) and includes food, entertainment and some alcohol)
Yes No
I would like to purchase additional Awards Function Tickets $125.00
* PLEASE NOTE: AWARDS FUNCTION IS INCLUDED IN THE FULL REGISTRATION PRICE ONLY
Name: _____________________________________________________________________________________________
NZIMRT Membership No. (if applicable): ��������������������������������������������������������������
PAYMENT DETAILS:
Payment type: (Please circle) Visa / Mastercard Cheque / Bank Cheque Internet Banking (Payable to NZIMRT Conference 2012)
TOTAL AMOUNT DUE: $NZ
Credit Card Number:
Print Name shown on Card: Expiry:
Signature: Date:
If you wish to pay by Internet banking please use the following account number:
NZIMRT Account Number: 15-3953-0268536-01
Please use the following references:
Particulars: Your NZIMRT Membership number (if applicable) Code: Your surname Reference: Conference 2012
Note: Accommodation is the registrant’s responsibility. The Hotel of choice is Crowne Plaza, Albert Street, Auckland. Contact reservations and quote ‘NZIMRT’ or use the link on the NZIMRT website. Also on the NZIMRT website are other close accommodation options for you to consider.
Parking costs at the Crowne Plaza: $24 overnight; $16 all day (8-6pm); $8 for the evening after 6 pm.
Refund Policy: Full refunds will be given up to 13/7/12. Thereafter, a fee of 10% will be deducted from the registration fee
Send completed form and payment to:NZIMRT Conference 2012 P O Box 16OakuraNew Plymouth 4345 New Zealand Telephone/Fax (06) 752 7040 E-mail: [email protected]
Full payment must accompany this registration. Registrations will be acknowledged within 7 days of receipt of payment.
