CRUSH 2011 - REGISTRATION AND PAYMENT FORM
Please note: one registration form to be completed for each delegate.
REGISTRATION DETAILS
Delegate Name: Institution: ___________________
E-mail address: Telephone: ______
Please indicate here if you do not wish for your details to be retained by the event organisers.
Please indicate here if you have any dietary requirements or special needs, and specify below:
______
TAX INVOICE
The Australian Wine Research Institute acting as secretariat for Crush 2011
PO Box 197, Glen Osmond SA 5064, Australia
The Australian Wine Research Institute Ltd ACN 007 558 296
REGISTRATION COST: $275 (includes the social program and Symposium Dinner)
LATE REGISTRATION (AFTER 31 AUGUST): $440
All amounts are in Australian dollars and include GST
Please forward this completed registration form and full payment to:
The Secretariat
Crush 2011
PO Box 197, Glen Osmond SA 5064, Australia
E-mail: crush2011@awri.com.au
PAYMENT
Credit Card
Please charge $ _______ to my Visa Mastercard Expiry date ____________
Card number ______ Cardholder’s name ______
Cardholder’s signature
EFT
I have sent an EFT payment for $ ________ to:
Commonwealth Bank of Australia,
BSB: 065-125 Account number: 351448
Account name: Australian Wine Research Institute Ltd
Please use delegate last name and company as reference and forward written confirmation of the
EFT payment to the Symposium Secretariat (email: crush2011@awri.com.au, or by fax: +61 (0)8
8313 6686)
NB: If you wish to pay by cheque please contact the Symposium Secretariat for instructions
For further information please contact the WIC Executive Officer, Carolyn Gadd, on telephone +61
8 8313 0929 or e-mail crush2011@awri.com.au