For which of the following are you applying:

							                                                                                                                                                                REGISTRATION FORM
                                                                                                                    Education Convention 2012
                                                                                                                                             FRIDAY, 13 JULY AND SATURDAY, 14 JULY

                        REGISTER EARLY TO AVOID DISAPPOINTMENT—REGISTRATION CLOSING DATE IS 25 MAY 2012


 Name:
 Position:
 Organisation:
 Postal address:
 Phone number:                                                                                                          Email:
       Do you have any special dietary requirements? If yes, please state:


 COSTS:
 GPEP attendees: RNZCGP will cover the cost of a standard room (including breakfast for one) and convention fees for
 GPEP teachers, medical educators, Fellowship assessors and Primex examiners. Additional costs, e.g. extra nights’
 accommodation, travel and extra dinner tickets will be at your own expense
 Other attendees: We welcome other attendees at a cost of $150.00 per day registration and $75.00 for the dinner or
 $350.00 for full registration (including dinner).
 I am:                           GPEP attendee                                               Other attendee
 I will attend:                  Friday, 13 July                                             Dinner—Friday, 13 July                                         Saturday, 14 July
 I will require additional dinner tickets at $75.00 each for (please name):

 ACCOMMODATION:
 To book your accommodation online, please visit the James Cook Grand Chancellor Hotel website:
 http://booking.ihotelier.com/istay/istay.jsp?hotelID=10799&userType=GRP.
 The code to access the group rooms and rates is RNZCGP35874.
 Alternatively, email group reservations at reservations04@jamescookhotel.co.nz or phone +64 4 495 0279 and quote
 RNZCGP Conference group booking number 035874.
 NB: As stated above, the College will pay for one night’s accommodation (breakfast inclusive) for GPEP attendees only.


 REMITTANCE ADVICE:                                                                                                                                         Total amount: $_______________
 NOTE: Payment only required for “Other attendees” or for extra dinner tickets.
 Please tick payment method and provide further information below if applicable.
       Cheque payable to RNZCGP (enclosed)                                                                                    Credit Card + 1% administration fee on amount paid
       Internet banking: Transaction date:                                           /               / 2012

 CREDIT CARD DETAILS:
       Mastercard                       Visa              Card number:


                                                                                      Expiry date:                      Month                     Year
                                                                                                                _____                     _____



 $
 _____________________________     ______________________________________________________________________________________________________________________

 Amount payable                    Cardholder name (Block letters)

 INTERNET BANKING:
 Please ensure your FULL NAME is included as a REFERENCE when paying by internet banking
 BANK: ANZ                                                                                                    ACCOUNT NAME: RNZCGP
 BRANCH: Lambton Quay, Wellington                                                                             ACCOUNT NUMBER: 010564 0047568 00

Privacy: Unless you advise otherwise, your name and email address will be included in the list of convention participants distributed to
participants and sponsors.

RETURN REGISTRATION FORM TO:
Linda Hartstonge | linda.hartstonge@rnzcgp.org.nz | Fax: 04 496 5997 | RNZCGP, PO Box 10440, Wellington 6143