REGISTRATION FORM

MUSCLE BALANCE ANALYSIS SEMINAR
Fairway Lodge Function and Conference Centre
7 Argus Place, Takapuna, Auckland
www.fairwaylodgeauckland.co.nz

5th & 6th MARCH, 2011

Saturday & Sunday, 8:30 a.m. - 5:30 p.m.

(NOTE: Sign in from 8:00 – 8:30 a.m. Saturday)

Name:_______________________________________________________________________________________

Phone:_________________________________________Mobile:________________________________________

 Address:_____________________________________________________________________________________

E-mail:________________________________________________Profession:______________________________


REGISTRATION
Note:  All prices include GST @ 15%, as well as morning and afternoon tea

I enclose (Please circle those that apply):
NZ$510    Standard registration, received through 25 Feb 2011
NZ$615    Late registration, received after 25 Feb 2011
NZ$  55    Goniometer (each) (Optional, but highly recommended; please click here for details)

______     TOTAL

REFUND POLICY:
Requests for cancellation of registration received by post, email, or fax on or before 25 Feb 2011 will receive a refund of all tuition paid, less an administrative fee of $100.00.  Due to the need to confirm seminar arrangements well in advance, refunds cannot be given for refund requests received after 25 Feb 2011.   MBA Pain Relief Seminars reserves the right to cancel any seminar, in which case all tuition paid will be refunded in full.  If a seminar is cancelled, MBA Pain Relief Seminars is not responsible for the costs of any guaranteed airline, hotel, or other travel reservations.   If a seminar is cancelled and you wish to transfer your registration from that MBA seminar to another, no transfer fee will be charged.


My method of payment is (Please tick one):
___   Cheque - Please make payable to:  Advanced Therapeutics, Ltd.

___   Internet Banking - To account # 38-9005-0864685-00 (Please reference your SURNAME)

Please do not enclose cash.

Please Fax your completed form to (09) 476 4948,

OR post this form with enclosed cheque to:

MBA Pain Relief Seminars

M110, Private Bag 300 987

Albany, Auckland

Signature___________________________________________________

For more information, please contact:
Kate Carlisle, C.N.M.T., R.N.  • PH: (09) 476 4949  • Mobile: 0274 206 147  • Email:  painrelief@paradise.net.nz