The Australian and New Zealand Society of Occupational Medicine Inc. (ANZSOM) Western Australia Branch Meeting & Annual General Meeting Join us at Perugino’s Restaurant on Wednesday 29th October 2014 Guest presentation: Fitness to Drive - Discussion of tricky cases by the DLA Occupational Physician Dr Michael Lucas When: Wednesday 29th October, 6.30pm for 7:30pm start Where: Perugino Restaurant 77 Outram St, West Perth www.perugino.com.au Cost: ANZSOM members Non-members and guests (Includes 3 course dinner) $70 (inc. GST) $90 (inc. GST) RSVP: Please register (preferably online) by Wednesday 22nd October 2014. ANZSOM Federal Secretariat PO Box 7032 Richmond VIC 3121 A.B.N. 49 465 909 950 A.R.B.N. 600 176 976 Phone: 1300 666 515 Fax: (03) 9428 4872 Email: [email protected] Web: www.anzsom.org.au ANZSOM Western Australia Branch October Meeting & AGM Wednesday 29th October 2014 Register and pay online via the ANZSOM website (www.anzsom.org.au) Alternatively complete your details below and forward to the ANZSOM Secretariat with payment by Wednesday 22 October 2014. nd Fax: (03) 9428 4872 Email: [email protected] Post: PO Box 7032, Richmond VIC 3121 TAX INVOICE / RECEIPT Name: _________________________________________________________________________________ Other guest(s): __________________________________________________________________________ Phone:__________________________ Email: ________________________________________ Special dietary requirements: ______________________________________________________________ Amount payable: _________________ ($70 members / $90 non-members) (Includes 3 course meal)  I am currently not a member and would like information about joining ANZSOM Methods of payment  Online – preferred option - complete payment online (the online booking process accepts credit card, payment can also be made by EFT after you have registered online, EFT details provided in the shopping cart)  Cheque – make payable to ANZSOM  Credit card* – complete details below and post or fax to (03) 9428 4872 * Please note: a 2% surcharge applies on all credit card payments. Credit card payments  Visa  Mastercard  Amex Card no: ___________________________________________ Expiry: _____ / ______ Name on card: ______________________________________ Amount: ______________ Signature: __________________________________________ This form serves as a tax invoice / receipt – please retain a copy for your records. An email will be sent to you to confirm payment has been made. A certificate of attendance will be issued following attendance at the event. ANZSOM Federal Secretariat PO Box 7032 Richmond VIC 3121 A.B.N. 49 465 909 950 A.R.B.N. 600 176 976 Phone: 1300 666 515 Fax: (03) 9428 4872 Email: [email protected] Web: www.anzsom.org.au