QAPon-line Registration Form

	PO Box 244 THE JUNCTION NSW 2291 AUSTRALIA
FertAid Pty Ltd [ABN 62-093-199-529] Quality Matters

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 1999

Registration Process

1. Read the page 'About QAP-online.com' including the Declaration.

2. Read 'About Subscribing to QAP-online.com

2. Read 'Review QAP Scheme available Read Fees

3. PRINT to PDF and email to office@Fertaid.com OR post to FertAid with payment.



	1998 Schemes

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

Individual	One Staff/One scheme	Discipline *	All staff/One Discipline
Scheme*	All staff/one scheme	Global *	Al Staff/All schemes
*,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.

Payment

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

Fee*	$USD	$AUD	Euro
Student	1000	11	500

*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: Card Holders Name [Please Print Clearly]:

VISA

MasterCard

Bankcard

CVV 3 Digit Authority Code

Name on Card:

Signature:

Expiry Date:

---

Direct Bank Transfer

Payable to Commonwealth Bank of Australia Acc Name: FertAid - Bank Code: CTBAAU2S

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::