These are hidden fields for the FORM element with defined names:- Do not edit

Values must be formula-referenced from VALUES sheet

Please register me for :-

(830am register for 9 am - 5:10 pm )

1 ) CONTACT DETAILS

First Name *

Surname *

-TITLE- Mr Mrs Ms Dr Prof

Company

Email *

Address

Postcode

Locality/Town

--STATE-- NSW QLD VIC ACT SA WA NT TAS

Work Phone

Mobile

Fax

2 ) ATTENDANCE

Thursday 1st Mar-->

Day 1 or Day 2 -->

Both days -->

Dinner only -->

* Day registrations also include lunch, tea and coffee

Cost (inc.)

I wish to attend ==>

------ Thursday Send Proceedings Only

""

Dinner (optional) ==>

FALSE

3 ) EXTRA COPIES OF PROCEEDINGS

I would like to collect ==>

0 1 2 3 4 5 6 7 8 9

?

...extra copies of the proceedings at the conference (@ $40 ea)

POST to me ==>

0 1 2 3 4 5 6 7 8 9

... copies of the proceedings (posted @ $50 ea)

Total- Due ===>

inc. GST

4 ) SUBSCRIBE

Please ..

delete include

..my contact details after the event on ICAN / GRDC’s mailing database of Northern Region Grains Professionals and Growers.

5 ) DIETARY REQUIREMENTS?

*** CANCELLATION / REFUND POLICY ***

We will happily refund your registration if notified by 20th February 2012. Cancellations between 20th and 27th February 2012 will incur a cancellation fee of $30. Refunds will not be provided for cancellations made after 27th February 2012.

*** REGISTRATION SUMMARY ***

Name :

Email :

Phone :

Fax:

Event :

I wish to attend :

Dinner :

Proceedings :

Dietary Requests :

""

Total Amount :

Add to Calendar (?)

If details are incorrect please scroll up to amend. Otherwise proceed to secure payment gateway.

Enquiries: ICAN Pty Ltd | Erica McKay | ph (02) 9482 4930

erica@icanrural.com.au

ICAN Website