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Skin Cancer Only

Workshop registration

Complete credit card authority and registration form

Register now below for:

a) Winter 2011 5 day flap and graft workshop

b) Face and ear 3 day reconstruction November 2010 workshop

Registration for all Skincanceronly workshops requires completion and submission of the following on line form. To pay for a workshop by credit card, download this credit card payment authority, complete it and FAX to Skincanceronly at 03 5243 4323. Note that registration is not confirmed until payment is made in full.

Registration form for all workshops

Complete this registration form and click "submit"

Full name*
Email address*
Street address*
Town / Suburb*
Post code*
State*
Country
Business phone number*
After hours phone number
Business fax number
Division of General Practice - (if applicable)
College affiliation for PDP points

PDP number or Date of Birth
I would like to register for the following event. (Select one)*

Events I have already attended? (Select one or more)




I plan to bring a partner to the workshop dinner. I understand an added cost is involved.*


I intend to pay for the workshop by*



My diet requirements are*




Comments
I consent to Skincanceronly providing my name and contact details to workshop sponsors*

Submit
*Required