Please print this form and send it with payment details to the address below:
Name : _______________________________________________________
Title : ________________________________________________________
Organisation : ________________________________________________
Address : _____________________________________________________
The program lists the title, name and institution of the licensee being the person responsible for confidentiality.
Licensee Title, Name and Institution or Address (80 characters):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Cost
New licensees: AUD$770 (includes GST)
Payment can be made by cheque or credit card
Cheques to be made payable to : CRUfAD St Vincent's Hospital Sydney
Return cheque and order form to: CRUfAD St Vincent's Hospital, Level 4 O'Brien, 394-404 Victoria St, Darlinghurst NSW 2010, Sydney Australia
Credit card details (Visa or Mastercard only):
Type of card : ________________________________________________________
Name on card : ________________________________________________________
Card Number : _________________________________________________________
Expiry date : __________________________________________________________
For further details regarding ordering the CIDI, please contact us.
