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PO Box 244    THE JUNCTION

NSW 2291 AUSTRALIA
FertAid Pty Ltd            [ABN 62-093-199-529] Connecting Professionals with Current and New Technologies  Phone: 61-(0)2-4963-1226
  Fax     :61-(0)2-4963-1228
TAX INVOICE - PLEASE PRINT AND POST or FAX 61-(0)2-49-63-1228 TO SUBSCRIBE WITH PAYMENT. www:fertaid.com - office@fertaid.com

Clinic (group) Subscription to QAPon-line at FertAid.com for 2027

**SPECIAL OFFER FOR ESHRE MEETING 2009- 50% discount for 2009 PLUS 2008 FREE ACCESS**

Scheme Number/Discpline
Please Note: The list displayed is only for scheme that require a paid subscription. Other schemes that are free are not displayed.
Type of Subscription
*,QAP-online will create a record of your subscription as the QAP supervisor and your Clinic as a QAP group. Your staff will be able to register online, link their registration to your QAP group and then enroll online without further payment. 
Individual One Staff/One scheme Discipline * All staff/One Discipline
Scheme* All staff/one scheme Global * Al Staff/All schemes
Payment

Please complete payment details for all staff in the one clinic. Please write clearly

Fee*
$USD
$AUD
Euro
Discipline
500
6
250
Student
500
6
250
Single
500
6
250
Scheme
500
6
250
Global
500
6
250

*inc GST

Individual One Staff- one scheme
Scheme All staff- one scheme
Discipline All staff - one discipline
Global All staff- all schemes

 
AMOUNT DUE: $USD $AUD Euro
Cheque Credit Card Bank Transfer Order Number
Credit Card Details VISA  MasterCard Bankcard 
Name on Card:    CV Code: Expiry Date:
       
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Direct Bank Transfer Payable to Commonwealth Bank of Australia   Acc Name: FertAid   Acc No: 062-821-1009-4608
Transferring Bank
      Date Transfer Requested:
 Order Number:   Name of Authorising Authority:   Signature:

Contact Details

Details of Clinic and Contact Details of Authorised Staff Member

[your logon code and  password will be sent to this e-mail if completed- please print clearly]

Office Use Only:Clinic:_________

Logon:_________Password:___________
Your Full Name:
  - Signature Date :
Institution/Clinic
 
Address:
 
:Telephone:
  Fax:
  e-mail address::