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REGISTRATION FORM - PowerPoint PPT Presentation

jessica-jarvis
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REGISTRATION FORM

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  1. REGISTRATION FORM Canine Hyperadrenocorticism Wednesday 8th July 2009 Vetnostics Training Room 60 Waterloo Rd North Ryde NSW Please complete the following registration form and return to Vetnostics with credit card details, cheque or vet code to: Vetnostics 60 Waterloo Rd NORTH RYDE NSW 2113 OR Fax: (02) 9005 7815 Name of Practice:_____________________________________________________ Name of Attendee (Vet) :_______________________________________________ Name of Attendee (Vet) :_______________________________________________ Name of Attendee (Vet): _______________________________________________ Name of Attendee (Vet) :_______________________________________________ Address:____________________________________________________________ Phone Number:____________________Fax Number:________________________ I enclose payment for No. of Vets ____________ Total Amount $_______________ Please tick the appropriate boxes I am paying by: Vetnostics Code: ______________ OR Chq OR Visa Bankcard M/card Amex Diners Club Card Number: Expiry Date:______________________ Card Holders Name:__________________ Signature:_______________________