FPQ EDUCATION PROFESSIONAL Course Registration Form

Print

This form is designed to be completed, printed and posted/faxed with payment or contact FPQ on 07 3250 0240.
Post: Family Planning Queensland, PO Box 215, Fortitude Valley, Qld 4006 Fax: 07 3250 0296 - ABN 61 009 860 164.
I understand that by lodging this form I am agreeing to FPQ's Terms and Conditions on Course Registration and Code of Conduct.

Date:  
Contact Name:     Title Mr Mrs Miss Dr
Organisation:  
Address:  
  POSTCODE:  
Home Address:  
Phone:   Mobile:  
Fax:   E-mail:  

How did you hear about this course?
FPQ will keep you updated about FPQ courses and news via email. Tick if you do not want this.

Education Professional courses: Cost
*GST Incl.		 Number Attending
no course available at this time $0
OFFICE USE ONLY:
Date received: participant notified of receipt: Date:
copy to: Teaching & Parenting Program Coordinatorr: Purchasing & Stores/Debtors Officer:

paying by:
Cheque
For $ enclosed
invoice
Please invoice (Company order form should accompany this form) Order Number:
Credit Card  
Visa  ............Mastercard  .............Bankcard
Credit Card Number: 3 digit security no.  
Name on card: Expiry Date:

 

Signature:__________________________________

 

Please debit: $

 

Invoice/receipt will be issued for Tax purposes.

 

Last Updated: 06-Oct-2008 11:09 AM  © FPQ