I have completed this document with the full understanding of my responsibilities in relation to delivering a CPD accredited activity and my typed name acts as my signature. Application Please forward your application and all supporting documentation to Lodgement Section 5 Billing Details These details will be used to generate an invoice for payment of the application fee Invoice / ABN Receipt to Contact Person Address Postal Address Suburb State Postcode Telephone Email Payment Please circle : Visa / MasterCard / Amex / Cheque Method Card No. Expiry Name on Signature card Bank - National Australia Bank EFT Account Name - The Pharmacy Guild of Australia Transfer BSB - 084 004 Account Number - 608 350 148 Please make cheque/money order payable to: The Pharmacy Guild of Australia, Queensland Branch Note: Please ensure that you include your invoice number in the reference field so we can identify your payment. Payment Terms and Agreement Accreditation fees are not transferable. Prices are subject to change. The final accreditation application outcome will not be finalised until full payment is received. Contact Us The Pharmacy Guild of Australia, Queensland Branch CPD Accreditation Phone: 07 3831 3788 Fax: 07 3832 0871 E-mail: Web:
I have completed this document with the full understanding of my responsibilities in relation to delivering a CPD accredited activity and my typed name acts as my signature. Application Lodgement Please forward your application and all supporting documentation to Section 5 Billing Details These details will be used to generate an invoice for payment of the application fee Invoice / Receipt to ABN Contact Person Postal Address Address Suburb State Postcode Telephone Email Payment Method Please circle : Visa / MasterCard / Amex / Cheque Card No. Expiry Name on card Signature EFT Transfer Bank - National Australia Bank Account Name - The Pharmacy Guild of Australia BSB - 084 004 Account Number - 608 350 148 Please make cheque/money order payable to: The Pharmacy Guild of Australia, Queensland Branch Note: Please ensure that you include your invoice number in the reference field so we can identify your payment. Payment Terms and Agreement Accreditation fees are not transferable. Prices are subject to change. The final accreditation application outcome will not be finalised until full payment is received. Contact Us The Pharmacy Guild of Australia, Queensland Branch CPD Accreditation Phone: 07 3831 3788 Fax: 07 3832 0871 E-mail: Web:
q-cpd-f8-v4-cpd-accreditation-application-form.docx