AMPS PROJECT-AUSTRALIA

ABN 50 327 934 894

Monday 26 September – Friday 30 September 2011

Holmesglen Conference Centre

Warrigal Road

CHADSTONE

AMPS Registration Form

Course fees include:

five days of AMPS training

the AMPS manual, provided to course participants

personalised AMPS computer scoring program, provided to trained raters at the end of course

refreshments each day.

Follow-up testing of 10 people to achieve reliability as an AMPS rafter is expected.

I ...... wish to apply for a place to attend the AMPS training course.

Contact Address Home:
Contact Address WorkPlace:
Phone (wk): / Fax (wk):
Phone (hm): / OT AUSTRALIA member no:
Email address:
Professional Qualifications (if OT student, specify course enrolled in):
Practice Area(s):

I enclose the following payment for AMPS Course Fees:

OT AUSTRALIA member fee: / $1,400.00 / [ ]
Qualified OT non- member fee: / $1,900.00 / [ ]
OT AUSTRALIAstudent member fee: / $1000.00 / [ ]
OT student non-member fee: / $1,200.00 / [ ]

PAYMENT DETAILS

I WISH TO PAY BY

 CHEQUE (made payable to AMPS PROJECT AUSTRALIA) CREDIT CARD

CREDIT CARD PURCHASE DETAILS

Credit card type:  VISA  Bankcard  Mastercard
Card number:
Expiry Date: ____ / ____
Signature______
Name appearing on credit card:______
Total amount due: ______

OR

PLEASE INVOICE MY EMPLOYER

Organisation: ______

Attention : ______

Address: ______

Send your REGISTRATION FORM and PAYMENT

(Cheques made payable to AMPS Project Australia) to:

OT AUSTRALIAVictoria

Attn: Cheryl Bermingham

PO Box 1286,

Fitzroy North, Victoria 3068, Australia

Tel: 03 9481 6866

Fax (+61 3) 9481 6844

Email:

“AMPS Project Australiais committed to supporting the National Privacy Principles. We will only collect and store information about you that is necessary. The information you provide may be used to offer, provide and improve our services to you. We will not otherwise, without your consent, use or disclose the information you provide for any other purposes unless it would reasonably be expected that such a purpose is related to the offer, provision and improvement ofAMPS Project Australia services and benefits to you or where such purpose is permitted or required by law.

Are prepared to have your name and address made available toAMPS Project Australia for undertaking research?

Yes No