Blank Medical Invoice Application - PDF

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Blank Medical Invoice Application - PDF Powered By Docstoc
					                        BLANK PAGE SUMMIT HARD YARN
                             APPLICATION FORM
              Applications must be received by 5.00pm WAST Monday 31st May 2010.

PERSONAL DETAILS
      Title                             First Name

 Surname                                                 Gender

Agency/organisation/group

Agency/organisation/group website      www.

Do you identify as an Aboriginal/Torres Strait Islander?     Yes/No (please circle)

 Business Hours Phone      (0___)                            Mobile   04

                   Email


        Postal Address
                                                                        Postcode
PERSONAL INTRODUCTION
In 100 words or less please tell us about yourself.




SUMMIT STATEMENT
In 100 words or less please tell us your reason/s for applying to join the Summit as a key contributor.
PERSONAL INFORMATION
TRANSPORT TO AND FROM BILLARD ABORIGINAL COMMUNITY

Monday 26 July 2010 (departures scheduled from Broome at intervals from 6.00am)

             Preferred mode of transport to Billard
                Aboriginal Community from Broome            Air charter (25-40 minutes)         4WD coach (2.5 hours)
     (please √ - if no preference, tick both options)

Friday 31 July 2009 (departures scheduled from Billard at intervals from 9.30am)

       Preferred mode of transport to Broome from
                       Billard Aboriginal Community         Air charter (25-40 minutes)         4WD coach (2.5 hours)
     (please √ - if no preference, tick both options)
OTHER REQUIRED INFORMATION

       DIET           Vegetarian                            Other (please specify): _____________________________________
                     Self-managed condition (will
MEDICAL                                                    Notifiable condition (please specify): ______________________
                     advise, if necessary)
    BODY                        For meeting payload requirements on air charter/s (please complete even if air
               ________ kgs
 WEIGHT                         charter is not your preferred mode of travel, in case of evacuation)
 T-SHIRT
                  S          M               L                XL              2XL             3XL              4XL
(please √)

PAYMENT ARRANGEMENTS


Please tick method of payment for registration fee of $2,690 inc GST:


                                                 Please   note that Billard Aboriginal Corporation:
                                                     -    does not accept payment by credit card;
      EFT                   Cheque
                                                     -    cannot manage late payments; and
                                                     -    registration unpaid after 30 days will lapse

                              Please state correct name and address for Tax Invoice
                (it will be forwarded to you with your invitation for processing within 30 days)
NAME:

ADDRESS:
SUMMIT COMMITMENT

In applying for the Blank Page Summit Hard Yarn, I agree to:

      •     arrive in Broome no later than the evening of Sunday 25 July 2010
      •     attend the Blank Page Summit for the full schedule of activities (Monday to Friday)
      •     join and contribute to a Blank Page Summit Working Group
      •     act in good faith in relation to the purpose and principles of the Blank Page Summit
      •     co-operate with physical arrangements at the Summit site to assist smooth running


Signature: ____________________________________________________________________           Date: _______/_____/2010


NEXT STEPS


1.          You will receive an acknowledgement of your application within seven days of submitting it.
            If your application is successful, you will be issued with an invitation and required to pay your
2.
            registration fee within 30 days.


1.          Scan and email as a pdf. to apply@blankpagesummit.com.au or
2.          Fax to (02)4267 4488.


                             Applications will be accepted up to Monday 31st May 2010.

				
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Description: Blank Medical Invoice Application document sample