FPQ MEDICAL AND HEALTH professional Course Registration Form

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 0294 - 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	Ms Mrs Mr Dr
Organisation:
mailing Address: (for invoicing)
mailing Address: (for invoicing)	POSTCODE:
Home Address:
Phone:	Mobile:
Fax:	E-mail:
medical/nursing registration no.	doctors qa&cpd ref. no.
Do you work in: General practice setting Community health Indigenous health Hospital Specialist sexual & reproductive health service Other 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.

Health Professional courses:		Cost *GST Incl.	Number Attending
	Introduction to Sexual and Reproductive Health Theory (self directed learning package)	$585
	Sexual and Reproductive Health Clinical Attachment Module - Dates individually negotiated	$550
	Pap Smear Provider Module - 10, 11, 12 February - Brisbane	$1010
	The Family Planning Australia Certificate in Sexual and Reproductive Health - Theoretical Component (for Medical Practitioners) ($1550 - full price; $1400 - early bird; $1000 - theory only; $550 Clinical Training only) - 14 - 19 March - Brisbane	$1550 $1400 $1000 $550
	Pap Smear Provider Module - 26, 27, 28 May - Cairns	$1010
	IMG GP Cervical Screening Update 1 day workshop - 29 May - Toowoomba	Free
	Pap Smear Provider Module - 14, 15, 16 July - Brisbane	$1010
	Clinical Aspects of Sexual and Reproductive Health - 21, 22, 23 July - Brisbane	$480 $380* *$100 discount if booked at same time as Pap Smear Provider Module
	Pap Smear Provider Module - 6, 7, 8 October - Brisbane	$1010
	The Family Planning Australia Certificate in Sexual and Reproductive Health - Theoretical Component (for Medical Practitioners) ($1550 - full price; $1400 - early bird; $1000 - theory only; $550 Clinical Training only) - 22 to 27 August- Brisbane	$1550 $1400 $1000 $550

OFFICE USE ONLY:
Date received:		participant notified of receipt:	Date:
copy to:	Training Programs Administration Officer: Purchasing & Stores/Debtors Officer:

paying by:
Cheque	For $ encl.
invoice	Please invoice (Company order form should accompany this form) Order Number:
Credit Card	Visa ............Mastercard .........
	Credit Card Number:	3 digit security no.
	Name on card:	Expiry date: ...
	Signature:______________________________	Please debit: $
Invoice/receipt will be issued for Tax purposes.

FPQ MEDICAL AND HEALTH professional Course Registration Form

Do you work in: General practice setting Community health Indigenous health Hospital Specialist sexual & reproductive health service Other 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.

Invoice/receipt will be issued for Tax purposes.

Do you work in:
General practice setting Community health Indigenous health Hospital
Specialist sexual & reproductive health service Other
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.