Network Mosaic Conference Registration Form

Network Mosaic Conference Registration Form (51 KB)

9.30am – 4.30pm, Tuesday 10^th August 2010

Kohia Teachers Centre
Seminar Room 1
Gate 1, 78 Epsom Avenue, Epsom, Auckland

This form can be used for individual and group registration. Please list all the names of those attending, with the key contact person entered first and then their contact details.

Payment Options

You can pay by cheque by posting a cheque with your name on the back and a copy of the registration form (you can download a copy above) to: SFMI PO Box 78 122, Grey Lynn, Auckland 1245.
Or
By depositing your fee into the SFMI bank account: ASB, Grey Lynn 12-3022-0347383-00. You must include your name/details under: particulars/code/reference on the deposit slip or internet banking page. By including these details it allows us to identify your payment.

Key Contact Name: *
2. Name:
3. Name:
4. Name:
5. Name
6. Name
7. Name:
8. Name:
9. Name:
10. Name:
Agency:
Postal address: *
Phone number (please include area code) *
Email: *
Conference Fee (please tick which option fee option you will be using)	Current Network Mosaic Members - No fee (only applies to membership prior to 1 July 2010) Non-members $50.00 per person Special offer $40.00 per person for group bookings of 5 or more Special offer to new members, annual membership to Network Mosaic & conference fee for one person only $75.00
Amount being paid:
Payment method:
The date you deposited fee is:
Please enter the characters shown in the image (Note this is case sensitive)

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Network Mosaic Conference Registration Form

Network Mosaic 0800 SFAUCK +64 (9) 378 9134