Murder and Mayhem conference: Registration Form
PLEASE RETURN WITH FULL PAYMENT BY 1 FEBRUARY 2004
| SEND
TO: Lona Gottschalk Murder and Mayhem Conference School of Languages, Cultures and Linguistics Building 11 Monash University VIC 3800 Australia FAX: + 61 3 9905-5437 |
| FULL NAME & TITLE: | |
| E-MAIL ADDRESS: | |
| NAME OF UNIVERSITY: | |
| PROFESSIONAL POSTAL ADDRESS: | |
| TITLE OF PAPER: | |
| DO YOU REQUIRE A SPECIAL DIET?: | |
a. vegetarian:
 | b. other: _________________ |
| EQUIPMENT FOR YOUR PAPER: | |
| a. OHP:
| c.
Slide projector: |
| b. Television+video: | d. other: _________________ |
| WILL YOU PAY: | |
| - delegate rate 250 How many? | |
| - Spouse / companion rate 250 How many? | |
| HOW DO YOU WISH TO PAY?: | ||
| CARD: | ||
| Visa | Mastercard
| American Express |
| ELECTRONIC
PAYMENT Please contact me to arrange an electronic payment: | ||
| CARD NO.:
| ||
| EXPIRY DATE: / CARD CHECK VALUE (CCV)*: | ||
| NAME ON CARD: | ||
I authorise Monash University
to charge my credit card 250. This will appear
on your statement in Australian dollars.
SIGNATURE:
IMPORTANT NOTE: Owing to University
regulations, once payment for the conference has been made we are
not able to offer any full or partial refunds. Please ensure that
you have adequate insurance to cover you should you be unable to
attend. Thank you.
* For Visa or MasterCard holders, the
CCV number is the three-digit number printed after your card number,
on the signature strip on the reverse side of your card