| PARTICIPANTS INFORMATION
|
| Name |
__________________________________________________________________________
|
| Organisation: |
__________________________________________________________________________
|
| Postal address: |
__________________________________________________________________________
______________________________________State: __________ Postcode:
__________
|
| Email: |
__________________________________________________________________________
|
| Phone/Fax: |
__________________________________________________________________________
|
| Mailing list: |
We will only use your details to inform you of future
New Pentecost initiatives. You may opt out at anytime.
[ ] No, don't add me to your mailing list.
|
| FEE |
| Fee: |
[ ] Whole day (including public lecture)
- $40 or $10* (please circle)
[ ] Public lecture only - $20 or $5* (please
circle)
* Fee will depend on what you can afford.
We have substantially subsidised cost. The more you give,
the greater our capacity to implement our program of building
greater cooperation among church groups. |
| Donation: |
[ ] To ensure the continual viability
of this Forum, I would like to donate $ ______________________ |
| Total: |
$ ______________________ |
| METHOD OF PAYMENT |
| Cheque / Money Order |
» Enclose Cheque or Money Order payable
to ACMICA, PO Box 306, Dulwich Hill NSW 2203.
Cheques/MO processed by ACMICA. |
| Credit Card |
I authorise the Edmund Rice Centre to debit my card:
[ ] VISA
[ ] MasterCard
[ ] BankCard
Card holder name: _______________________________________________________
Card number: ___________________________________________________________
Expiry date: ______________
Authorisation signature: ___________________________________________________
Credit card payments processed by the
Edmund Rice Centre. |
Cash: |
[ ] I'm paying by cash |
