Course Registration And Payment

Course Registration and Payment Please reserve a position in: Name of course: ……………………………………………………Course fee: $……………………... Starting date: ……………………………………………………….Course location: .............................

Applicant Surname (family name)........................................................... Given names ............................................... Postal address: ................................................................................................................................................ ........................................................................................................................................................................ Telephone no (H) .................................... (W) ........................................... (Mobile) .................................... Email : ........................................................................................................ Fax: ..........................................

Payment details I have enclosed payment of $.......... (cheques payable to NSW Department of Primary Industries). Signature: _______________________________________ Date: _____________________________ Please charge payment to my credit card. My full card number is:

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Name on card: ____________________________________ Expiry date: _______________________ Signature of cardholder: ________________________________________________________________

Refunds and Withdrawals If a course has been fully booked, fees of later applicants will be refunded and the applicant given priority at future courses. Any withdrawal or transfer from a course must be received at least five working days before the course date to receive a refund less an administration fee of $50. No refunds or transfers will be given if notified within five working days of the course date Office use only – course coordinator to fill out return details before sending form. Please return this form with payment two weeks before the course date to: Name: ....................................................................................................................................................... Address: ................................................................................................................................................... ................................................................................................................................................................... Phone no: …………………………………………..Fax no: ……………………………….

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Version 6 – 09/09 JH