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					                 Adult Literacy Practitioners’ Association Incorporated
                                         ALPA Inc.

                     Registration Form for ALPA National Hui/Conference 2012
                             “Measuring success: Opportunities and Challenges”

                                                   Friday 29 June to Sunday 01 July 2012
                                                        AUT University, City Campus

Surname:                                                                             First name:

Town/City:                                                                           Post code:
Land-line:                                                                           Mobile:

The Privacy Act 1993 requires that, before your name and organisation details can be published in the list of delegate either for distribution to fellow delegates or any other
party, you must give your consent. If you DO NOT wish your name and details to be included in the list of delegates please tick.

       Please fill in one box only,           current financial member                                  OR       non-member

                      Current Financial Member                                    OR                                       Non-member
Item                                               Cost    Your payment                     Item                                                 Cost     Your payment
                                                      $    Please write in the                                                                      $     Please write in
                                                           amount or ‘ – ‘                                                                                the amount or ‘ –

Conference dinner                                 50.00                                     Conference dinner                                   50.00
Research Forum                                                                              Research Forum only
Friday                                          150.00                                      Friday                                             200.00
Conference                                      250.00                                      Conference                                         300.00
Saturday and Sunday                                                                         Saturday and Sunday
Early Bird: before 27April                      350.00                                      Early Bird – before 27 April                       450.00
Combined Research Forum and                                                                 Combined Research Forum and
Conference       OR                                                                         Conference            OR
Standard: 28 April –31 May                      400.00                                      Standard: 28 April–31 May                          500.00
Combined Research Forum and                                                                 Combined Research Forum and
Conference                                                                                  Conference
Late registration – after 31 May                  50.00                                     Late registration – after 31 May                    50.00
Additional $50 for forum/conference                                                         Additional $50 for forum/conference
                                               TOTAL                                                                                         TOTAL

Payment Summary: (ALPA is not GST registered)

Form of payment:                                cheque payable to ALPA Inc.

                                                Direct credit payments can be made to Westpac                               03 0850 0107576 00
                                                Please include your full name as a reference. Please post or email application form

Please advise us of any special requirements including dietary needs:

Cancellation and refund policy:
Should you need to cancel your registration, you may reassign your registration to another person. Please notify ALPA in writing of your cancellation or
replacement. If you are unable to arrange a replacement, a refund less a $100.00 cancellation fee will be made provided notification is received by 30 June
2010. After that date, refunds will be at the discretion of the organising committee.

Please email your registration form to

       Office Only: Membership no.                                      Receipt no.                                     Banked

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