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

Participant Registration Form (Buy In)
 
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.
   
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 buy-in cost of $4,000.00 (or $5000.00 if single accommodation preference indicated above) to be deducted from the venue’s October account. Please tick the following box to agree.