2015 aicla (vic) awards and diary presentation
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(For credit card payment confirmation to be forwarded)
This is a Tax Invoice. Please retain a copy for your records
We look forward celebrating our night with you
Registration Form & Tax Invoice
COMPANY:
NAME:
NAME:
Attach List if Insufficient Space
No. __________ X $____________ Total Cost
$____________
I enclose my cheque for $ payable to AICLA or
If you wish to pay by credit card please complete below:
Mastercard (please circle)
Visa Amex
Cardholders Name:
Card Number:
Expiry Date: Amount: $
Signature:
Email Address:
Forward Completed Form to: