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
$250 (GST-inclusive)
Discounted fee for multiple enrolments from one practice/clinic
$225 (GST-inclusive)
Payment options
Direct credit payment to ASB account
GLAUCOMA NEW ZEALAND
12-3013-0180964-00
Date of direct credit:
DD
1
2
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7
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9
10
11
12
13
14
15
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19
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28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2010
2011
2012
2013
Amount paid:
$250
$225
Credit Card
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