First name

Surname

Phone Number

Email Address

Postal Address

What type of registration do you require?

Full Conference - Member ($375 per person)
Full Conference - Non-Member ($449 per person)
Legionella Seminar Only - Member ($195 per person)
Legionella Seminar Only - Non-Member ($235 per person)

Do you have any Special Dietary Requirements?

Yes
No

If yes, what are your dietary requirements?

Will you be attending the Conference Dinner on Thursday 29th August 2019?

Yes
No

Will you be bringing a guest to the Conference Dinner on Thursday 29th August 2019? (NOTE: $75 for additional ticket)

Yes
No

If booking an additional ticket for the dinner, what is your partner's name and dietary requirements?