2005 Conference Registration Form

Delegate Information (*denotes mandatory fields)

Title*

Family Name*

First Name*

Occupation*

Position*

Division*

Organisation*

Postal Address*

Street Address

Suburb*

State*

Postcode*

Country*

Telephone*

Facsimile

Email*

Web Address

Delegate & Student Registration Entitlements Include

• Admission to Opening Ceremony
• Morning & Afternoon Teas
• Admission to Delegate Exhibition

• Conference Satchel
• Admission to all Programme Sessions
• Sunday Evening Drinks and Canapés

Registration Fees

Fee Category

Price

Delegate

AU $880

Full-Time Student**

AU $550

Group (min 5)***

AU $800

** Student: You must fax or mail a photocopy of your student ID or a letter from your training director
*** Group: Each delegate must fill in a seperate registration form and all forms must be lodged together. This cannot be completed online. Please download registration form here

Gala Dinner with Dr David Suzuki (Please select number of tickets form the drop-down menu)

Friday 18th March 2005 at Brisbane City Hall & King George Square
Drinks under the stars, three-course meal and refreshments provided.

Gala Dinner

Special Dietary Requirements

Email Newsletter

Would you like to receive our free newsletter? You may unsubscribe at any time.
To receive this newsletter, you must fill in your email address in Delegate Information section

Registration Total (including Registration & Gala Dinner)

Total

AU $

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Optional Survey (Please type in the box)

Where did you hear about the 2nd International Conference on Healthy Ageing and Longevity?

Your Comment

In registering for this Conference, relevant details will be incorporated into a participant list for the benefit of all delegates (name and organisation only). Details may be provided to parties directly related to the Conference.
Please tick the box if you do not wish to have your name included in the participant list.
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©2004 International Conference on Healthy Ageing and Longevity is presented by Holistic Health & Longevity Pty Ltd. ABN 140 541 401 53
Conference Programme developed by the International Research Centre for Healthy Ageing and Longevity Ltd. ABN 121 072 940 39

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