INTERNATIONAL SOCIETY FOR HEART RESEARCH
AUSTRALASIAN SECTION
Aging Heart & Vessels
ALFRED HOSPITAL & BAKER HEART RESEARCH INSTITUTE, Melbourne, 3-5th AUGUST 2004
Title:
First Name:
Family Name:
Full address:
Telephone number:
Facsimile number:
Email address:
I have downloaded & used the official form in MSWord & saved the file as "ISHRage name1.rtf" in rich text format. I have sent this electronically by email to spepe@baker.edu.au & have attached a signed, printed copy of this application form. yes [ ] no [ ] Or
Before April 15, 2004, I will be submitting an abstract with the title & authors: " ................................................................ .. . .." yes [ ] no [ ]
I,.............................................. ................................................................
certify that .......................................... .................. .....is an enrolled student
at .................................................................................... ......during 2004.
supervisor's signature....................................... ......date ............
title/position.......................................................................... .............. ..
D. REGISTRATION FEE
Total fee includes
the cost of
Refreshment breaks,
Tuesday Welcome Reception, Tuesday & Thursday Lunches,
and Wednesday
Night Conference Dinner.
Early Bird Rate
Register by April 15th
Tick Box:
1. ISHR member
$ 380 [ ]
2. Full-time student,
with supervisors statement
$ 280 [ ]
3. Non-Member Registration
(be
a member & pay less ! Can be sent with this form)
$ 480 [ ]
4. Late Registration
(after
April 15th) ADD $50
$ 50 [ ]
5. I am including
my membership fee for 2004
full membership $ 55 [ ]
SEA/Pacific membership $ 45 [ ]
student membership $ 44 [ ]
(Please attach
membership form. Membership form available at http://www.baker.edu.au/ishr/membersh.htm
)
(Note: Membership
financial status will be verified with all sections.)
6. If applicable: I
am not able to attend the wednesday night dinner
subtract $ 80
[ ]
7. Special Dietary requirements________________________________________________________
8. Although included in registration, for catering purposes please indicate
whether you will attend:
[ ] Tuesday Evening Welcome Reception
[ ] Tuesday Lunch
[ ] Thursday Lunch
9. I am interested in tour options (Wednesday afternoon) please include
me & send more information.
[ ] Dandenongs, Yarra Valley & Healesville
Wildlife Sanctuary
[ ] City & Bay tour
[ ] I prefer own arrangements/ free time
TOTAL PAYMENT ENCLOSED $____________
(All costs listed include 10% GST, ABN 93
178 182 612)
Pay by Credit Card: COMPLETE & FAX FORM TO +61 3 85321314
Total Amount to Pay: $_______________ Card Type: VISA [ ] MasterCard [ ]
Name on Card: ______________________________________________________________
Card Number:
Expiry:
Signature:
________________________________________
Cheque:
Please make all
cheques payable to "International Society for Heart Research"
and send with this
form to:
Dr. Salvatore Pepe,
Secretary, ISHR Australasian Section
P.O. Box 6492, St
Kilda RD Central, Melbourne, VIC 8008, AUSTRALIA
(please advise by
email you have registered and when posted)