Registration and Payment Form   

[ For further information, CLICK HERE. To view the program, CLICK HERE. ]

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

TYPE OF REGISTRATION	Member	Non-member
Social Entrepreneur	$165	$220
Third Sector	$286	$352
Academic /Researcher	$286	$352
Government /Public Sector	$363	$440
Corporate Sector	$363	$440

I will be attending as a

          Please choose Social Entrepreneur Third Sector Participant Academic/Researcher Government/Public Sector Participant Corporate Sector Participant


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 26 August 2005. Social Enterprise Partnerships Ltd ABN 47108742098 2 Elm Street North Melbourne Phone (03) 9326 4481 Fax (03) 9326 8030