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Exercise Science & Rehabilitation Centre, Building 13, University of Wollongong NSW 2522

"WORKCOVER APPROVAL COURSE FOR EXERCISE PHYSIOLOGY PROVIDERS"
2007/2008

Please complete all the details below and return by fax/post to ESRC at the above address.
Phone 02 4221 3057. Fax 02 4221 5717.

First Name Last Name
Address    
Phone (H) (W) (M)
Fax (H) (W)
Email    
Workcover Provider No AAESS No
Location Course Date
Total Cost $150.00    
Payment Credit Card Cheque Card Type Card
Credit Card Details - - - Expiry Date /

 

Signature: __________________________________ Date: _________________

Registrations will only be accepted on an official registration form. One per delegate is required. The personal information on this form will be held in the strictest confidence.
Any cancellations will be re-booked subject to availability.

Office Use:

Confirmation email sent: Signature ________________________ Date: _______________