email:   australia@hadassah.org
tel:   1800 HADASSAH  (+61 3 9500 2681)

2010 Hadassah Australia Public Forum -
Infant Male Circumcision

Sydney, Monday 23rd August 2010 at 7:00pm

Credit Card Bookings

Please complete and submit the form below.
When you click "Submit" you will be automatically redirected to Westpac PayWay
for secure processing of your credit card payment. Email confirmation will be sent.

Fields shown with * must be completed.

Your Details:

First Name*: Surname*:
       
Email*: Salutation:
       
Preferred Phone*: Alternative Phone:
       
Address Line 1: Address Line 2:
       
City / Suburb: State: or other:
       
Post / Zip code: Country:
       
 
No. of Seats: @ AU$10.00    
       
Total $: < THIS AMOUNT WILL BE CHARGED TO YOUR CREDIT CARD
 
Details of other attendees
  Attendee name   Attendee Contact (email or phone)
1:  

2:  

3:  

4:  

5: