Course Registration and Payment

Please reserve a position in:

Name of course: ……………………………………………………Course fee: $……………………...

Starting date: ……………………………………………………….Course location: .............................

Applicant
Surname (family name)........................................................... Given names ...............................................
Postal address: ................................................................................................................................................
........................................................................................................................................................................
Telephone no (H) .................................... (W) ........................................... (Mobile) ....................................

Email : ........................................................................................................ Fax: ..........................................

Payment details
I have enclosed payment of $.......... (cheques payable to NSW Department of Primary Industries).

Signature: _______________________________________ Date: _____________________________

Please charge payment to my credit card. My full card number is: Circle one logo only

Name on card: ____________________________________ Expiry date: _______________________

Signature of cardholder: ________________________________________________________________

Refunds and Withdrawals

If a course has been fully booked, fees of later applicants will be refunded and the applicant given priority
at future courses. Any withdrawal or transfer from a course must be received at least five working days
before the course date to receive a refund less an administration fee of $50. No refunds or transfers will be
given if notified within five working days of the course
date
Office use only – course coordinator to fill out return details before sending form.

Please return this form with payment two weeks before the course date to:
Name: .......................................................................................................................................................
Address: ...................................................................................................................................................
...................................................................................................................................................................

Phone no: …………………………………………..Fax no: ……………………………….

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