TITLE:
____________________________________________________________________
NAME:
_____________________________________________________________________
NICKNAME:
________________________________________________________________
ADDRESS:
__________________________________________________________________
DATE
OF BIRTH: ____________________ COUNTRY:
_____________________________
UNIVERSITY:
_______________________________________________________________
YEAR
LEVEL: __________________ EMAIL:
_____________________________________
CONTACT
NUMBER: _________________________________________________________
FLIGHT
NUMBER (IF KNOWN): _______________________________________________
DATE
OF ARRIVAL: _______________________ T-SHIRT
SIZE: ____________________
SPECIAL
DIETARY REQURMENTS*:
__________________________________________
REGISTRATION
FEE:
Full
fee or US$100 by April 15th, 2002 to secure place.
Remaining
fee can be paid upon arrival.
Payment
Options :
Telegraphic
Transfer (from your account into our account).
Account
name - Asian Pacific Dental Student Association of Australia
BSB
¡V 105 : 120 - Account number ¡V 23885240
:Hughes
Plaza, Nth Terrace, Adelaide, SA 5006.
Draft (International Cheque which is posted to us).
Payable
to Asian Pacific Dental Student Association of Australia
Please
fill in your details and send with your payment back to:
Andrew
Cheng
3
Ellis Street, Magill SA 5072
or
phone on: 0408 168 728 or e-mail: ahacheng@hotmail.com
* All meat provided in meals will be Halal meat.
