Registration and Payment Form   

Please provide the following contact information

Name
Title
Organisation
Work Phone
Fax
Email

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

Please describe your current role and the sector you work in

REGISTRATION	Member	Non-member
Unsalaried	$220	$330
Third Sector - Staff of funded organisations	$440	$550
Public Sector - Staff of government and public sector agencies	$550	$660
Small Business - Staff of businesses employing up to 10 people	$440	$550
Corporate - Staff of businesses employing more than 10 people	$550	$660
Full-time Student	$220	$330

    * All of the rates shown include GST

 I will be attending as a

  Please choose Unfunded Third Sector Public Sector Small Business Corporate Full-time Student

  I would like to invite a guest/s to the National Awards Dinner (cost - $75pp)

  Please send me information on accommodation at Novotel St Kilda

        
  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) Individuals 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 consultancy organisations
		Research Associate - $286 p.a. (includes GST) Individuals in research or academic 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.)

Please reserve my place and

	I will send my cheque/money order to   Social Enterprise Partnerships,
		2 Elm Street
		North Melbourne VIC 3051
OR

I will make a payment using our secure online credit card payment facility (Visa/Bankcard/Mastercard accepted) CLICK on this link NOW to use our secure payment system. Then close the window and submit this form.

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

PRIVACY STATEMENT:  Registration details will be held in the strictest confidence and will not be passed onto a third party. CANCELLATIONS:  Cancellations must be notified in writing by 7 October 2006. Social Enterprise Partnerships Ltd ABN 47108742098 2 Elm Street North Melbourne Phone (03) 9326 4481 Fax (03) 9326 8030