Please provide the following contact information

Name
Title
Organisation
Work Phone
Fax
Email

Address
Address
City
State	QLD NSW ACT VIC TAS SA WA NT N/A
Postcode
Country

          Please describe your current role

REGISTRATION FEES (NOTE: prices include GST)	Full Reg'n*	Day 1	Day 2 plus Dinner	Day 3	Dinner Only
Social Entrepreneur or Community Partner                    - member                  - non-member	$275 $550	$55 $220	$165 $330	$55 $220	$165 $165
Third Sector - member                  - non-member	$440 $550	$165 $220	$220 $330	$165 $220	$165 $165
Academic - member                  - non-member	$550 $660	$165 $220	$330 $440	$165 $220	$165 $165
Government and Public Sector                  - member                  - non-member	$880 $1276	$165 $253	$660 $770	$165 $253	$165 $165
Corporate Sector - member                  - non-member	$990 $1430	$220 $330	$660 $770	$220 $330	$165 $165

* Full registration includes all four events.

I wish to attend this event as a

          Social Entrepreneur (SEP member) Social Entrepreneur (non-member) Community partner (SEP member) Third sector SEP member Third sector non-member Academic SEP member Academic non-member Government or public sector SEP member Government or public sector non-member Corporate sector SEP member Corporate sector non-member

I will be attending

          Conference, Dinner and both Workshops Conference, Dinner and Day One Workshop Conference, Dinner and Day Three Workshop Day Two Conference and Dinner only Workshops only - Days One and Three Day One Workshop only Day Three Workshop only Dinner only

and I would like to bring guest(s) to the Conference Dinner (optional).

MEMBERSHIP APPLICATION (optional)

	I would also like to become a SEP member in this category (please check a box)
		Community Partner - $77 p.a. (includes GST) Unfunded community leaders and initiative-takers
		Social Entrepreneur - $99 p.a. (includes GST) Individual social entrepreneurs who can demonstrate enterprise achievements (Please include details of your achievements in the text box above)
		Third Sector Partner - $187 p.a (includes GST) Individuals in funded organisations in the third or community sector
		Civic Entrepreneur - $242 p.a. (includes GST) Individual civic entrepreneurs in government and public sector agencies
		Corporate Associate - $286 p.a. (includes GST) Individuals in private sector organisations
		Consulting Associate - $286 p.a. (includes GST) Individuals in research or academic organisations
		Research Associate - $286 p.a. (includes GST) Individuals in consultancy organisations
		Student Associate - $33 p.a. (includes GST) Full-time students
For information on Member benefits, please CLICK HERE. (Close the window when you are ready to return to this form.)
PAYMENT DETAILS
	I will send a cheque/money order to
			Social Enterprise Partnerships Suite 509, 208 Forest Road Hurstville 2220
OR

I understand that a secure online credit card payment facility is currently being installed. Please advise me by email when this is set up so I can make a credit card  payment*.        * Visa/Bankcard/Mastercard accepted.

I understand that a tax invoice/receipt will be forwarded to me on receipt of this message.