Registration of Interest Form

Please note, this is a registration of interest form only. Please either download the credit card payment form and send/fax it to:

Fulbright Symposium 2007 Registration
Centre for Muslim States and Societies (M259)
University of Western Australia
Stirling Highway
Crawley, WA 609

FAX: +61 8 6488 4558

Or mail your cheque addressed to “The University of Western Australia” to the Centre for Muslim States and Societies. This will finalise your registration for the event. An email confirming receipt of your payment will be emailed to you. A receipt may also be mailed to you should you require it.

Personal Details:

Name:

Position:

Telephone:

Email Address:

Registration Package

Please tick the registration package:

	Full 3-day Registration (AUD$250)
	Concession Full 3-day Registration (AUD$100)
	First Day Registration Only (AUD$50)
	Concession First Day Registration Only (AUD$40)
	AIIA Member Only ($40)

Day 1 - 1 August - Dinner (optional)
You are invited to attend a dinner with the speakers at the conclusion of the first day of proceedings. Dinner will be held at the University Club, cost $55 per person.

Please include the cost of the dinner to your payment.

	Yes, I would like to attend the dinner ($55 per head)
	No, I would not like to attend the dinner