Registration
Enrolment Glaucoma NZ Professional Education Programme
Title:
* First Name:
* Last Name:
Occupation:
Practice or Clinic:
* Address:
Postcode:
Telephone:
Email:
Have you previously enrolled with Glaucoma NZ?
Yes
No
Receipt to be issued in the name of individual or practice/clinic?
Individual
Practice/Clinic
Fee options
Professional membership programme
$260 (GST-inclusive)
Discounted fee for multiple enrolments from one practice/clinic
$240 (GST-inclusive)
Payment options
Direct credit payment to ASB account
GLAUCOMA NEW ZEALAND
12-3013-0180964-00
Date of direct credit:
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/
MM
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2
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/
YYYY
2012
2013
2014
2015
Amount paid:
$260
$240
Credit Card
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