PARTICIPANT 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) - $50 or $10* (please circle)

[   ]   Public lecture only - $20 or $5* (please circle)

* Whatever you can can afford. We have substantially subsidised cost. The more you give, the greater our capacity to implement our vision of building greater dialogue and 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.

Cheque & money order processed by ACMICA (www.acmica.org)

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 (www.erc.org.au)

Cash:

[   ]   I will pay by cash on the day