'The person books built'

Membership Registration Form

Please complete a membership form for each person joining. Mark which membership type you are purchasing. Payment for multiple memberships can be made on the one payment.

	Full	Concession
Attending Membership (till 1^st May 2007)	$AUD175	$AUD132
Supporting	$AUD33	N/A
Students (15 years and older)	$AUD55	N/A
Children under 15	No charge	N/A
Day Rate	TBA	TBA

All prices include GST

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First Name Last Name

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Name on Badge

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Address for Postage (Street or P.O.)

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Suburb State Postcode

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Phone Email Address

o I do not want my name & state on any public member list. o I do not want to receive email from Convergence 2.

o I want to volunteer o I want to participate on the program

Total Payment (……… memberships): $_____________

If paying for more than one membership attach a form for each person joining

I enclose a cheque/money order payable to “Vic SF Conventions” for the above amount.

Please debit my o Visa o Bankcard o Mastercard for the above amount.

Unfortunately, we cannot accept American Express or Diners Club Charge Cards

Cash payment may be made directly to the Membership Officer.

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Card Number Expiry Date

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Name on Card Signature

Membership applications and payments (cheque/money order or credit card) may be mailed to:
Membership, Convergence 2, GPO Box 1212, Melbourne 3001 or
emailed to convergence at natcon dot org dot au (credit card payments only)
– convert this form into a pdf or scan and send as an attachment

http://www.natcon.org.au/2007
email convergence at natcon dot org dot au or phone 0418 540 160

Payment may also be made through Paypal. Go to www.paypal.com and click Send Money.

 Recipient's email is 2007_treasure at natcon dot org dot au  Category of purchase is Goods (Other)  Subject is Membership Payment

 In Note enter your name, address, contact email or telephone, type of membership.