Building 5 Campbelltown CampusLocked Bag 1797, PENRITH NSW 2751

T (02) 4620 3284 F (02) 4620 3291 www.nicm.edu.au

RACI NATURAL PRODUCTS CHEMISTRY GROUP ANNUAL

ONE-DAY SYMPOSIUM 2015

Registration Form

Attendee Information

Name: Title:First Name Last Name .

Name for Badge .

Organisation:.

Phone: Email:

Address:Street Address

City State Postcode

I wish to present orally (tick)YES NO

I wish to present a poster (tick)YES NO

Payment Method

Registration fee includes lunch, tea breaks, abstract booklet. Drinks and canapés to be provided after the event and are included in the registration fee.

*As is our custom, students giving an oral presentation will have their registration fee waived.

Prices shown are for registration up to 2 September 2015.After this date, registration costs are $10.00 extra.

Building 5, Campbelltown CampusLocked Bag 1797, PENRITH NSW 2751

T (02) 4620 3705 F (02) 4620 3291 www.nicm.edu.au

Page 2 of 2

Please tick one box:

$80 (RACI MEMBER) $85 (NON-MEMBER)

$50 (RACI STUDENT) $50 (STUDENT NON-MEMBER)

Pay by:CREDIT CARD CHEQUE MONEY ORDER

Made payable to: RACI 505 NNG OneDaySymp 10/15

Send completed form and payment to: Pam ChantrellRACI NSW Branch Co-ordinatorSchool of Chemistry, The University of New South WalesSydney, NSW 2052Email: r ac i - n s w @ r a c i . o r g. a u Fax no: 9385 6141

NB: The completed registration form must be received by the organisers by fax, email or postNO LATER THAN C.O.B. Friday, 25 September 2015

CREDIT CARD AUTHORITY

Amount $: (RACI Natural Products Chemistry Group One-Day Symposium, 2015)

Type of Card (tick):

Card #:

Expiry Date: /

Name of Card Holder:First Name Last Name

Cardholder’s Signature Date: