Tatts Pokies Excellence High Achievers Trip
Vietnam - 30 September - 07 October 2008
(Fully Funded Form))

Participant Registration Form (Fully Funded)
 
First Name :
Last Name :
   
Venue Name :
Badge Name :
   
Address :
Suburb :
State :
Email Address :
Work Phone :
Home Phone :
Mobile Phone :
Date of Birth : (dd/MM/yyyy)
   
Emergency Contact Name :
Emergency Contact Phone :
Emergency Contact Mobile :
   
Passport Number :
Nationality :
Place of Issue :
Date of Issue :
Expiry Date :
Birthdate :
Sex : Male
Female
   
Dietary Requirements :
No Read Meat
Other Dietary Requirements :
   
Medical Information :
If you have any allergies, pre-existing medical conditions or are taking medications, please include details including your Doctor’s name, phone number and address. Alternatively please FAX details to 03 9686 2277.
   
Travel Insurance :

   
Travel Seating Requests :
(Requests cannot be guaranteed)

Accommodation (Sharing with) :
Accommodation (Single) : Yes
Single accommodation at an additional cost of $1,000 per person is preferred (subject to availability) and this cost will be charged to the venue’s October account.
Travel Extension : Yes I would like to extend my trip and will contact Travel Design on Ph: (03) 9686 2555 to discuss alternative travel arrangements.
   
Attendance at briefing: Yes I will be attending the briefing at Tattersall’s
(615 St Kilda Road), on Tuesday September 23rd at 4.00pm.
No I will not be attending the briefing.
   
Buy In's :

Is there anyone else from your venue buying in to this trip?
Yes
If yes, what is their name? (this person must complete and register on the link for buy in)
   
Other comments :

   

DECLARATION : I hereby authorise the abovementioned representative to participate in the ‘Tatts Pokies Excellence High Achievers Trip 2008’ on behalf of our venue and authorise the additional cost ($1,000 single accommodation - only if indicated above) to be deducted from the venue’s October account. Please tick the following box to agree.