Conference Registration Form Conference Registration Form Name* First Last OrganisationIndustry Grains Livestock Poultry Dairy Wool Horticulture Forestry Fisheries Sugar Bush Foods Natural Resource Management Professional Services Research Education Agribusiness Student Other Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneMobileEmail Facebook URL Twitter HandleLinkedIn URL Medical Conditions & Dietary Requirements:Do you have any dietary requirements, allergies or medical conditions you would like us to know about in case of emergency? Is so please provide details below:Emergency Contact Details:Emergency Contact NameRelationshipEmergency Contact Telephone NumberInformation SharingAre you happy for your name, organisation, industry, state and email to be shared with other delegates?*YesNoTalent Release AuthorityYou may be photographed or filmed by AWiA with the recorded image/film/audio being used on social media, advertisements, other promotional items or through news outlets (television, social, radio, paper, magazine) only in relation to Australian Women in Agriculture. Is this acceptable?*YesNoAre you of Aboriginal or Torres Strait Islander descent?*YesNoIs there anything specific or special you would like AWiA to consider when using your image and/or your audio-visual recordings? Please provide details below.*YesNoConference TicketsPlease note Individual Gala Dinner tickets can only be purchased by a full conference registration ticket holder.AWiA Member Registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner Price: $ 400.00 Quantity: Non-Member Registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner Price: $ 500.00 Quantity: Full Time Student Registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner Price: $ 360.00 Quantity: Conference Tours Only (past) Price: $ 70.00 Quantity: Conference Tours Only (present) Price: $ 70.00 Quantity: Conference Tours Only (future) Price: $ 70.00 Quantity: Individual Event TicketsIf you can not attend the whole conference, why not attend one of the events below? Partners and friends are also welcome at our events.AWiA Member Friday Night Cocktail Function Price: $ 70.00 Quantity: Non-Member Friday Night Cocktail Function Price: $ 80.00 Quantity: AWiA Member Saturday Night Gala Dinner Price: $ 100.00 Quantity: Non-Member Saturday Night Gala Dinner Price: $ 120.00 Quantity: Saturday Day Sessions Only Rate Price: $ 120.00 Quantity: This ticket allows the purchaser to attend the Saturday Conference sessions. It does not include the Gala Dinner. Opening Event or Bus Tours.Payment OptionsCredit Card — Pay NowDirect Deposit - BSB 037-608 Account 524119ChequeOtherThere is an additional 1.7% fee for credit card payments.Credit Card Fee Price: $ 0.00 Total Conference Costs $ 0.00 Please note: Conference registration is not confirmed until payment is received.Credit Card MasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Westpac BSB: 037 608 Account number: 524 119 Use your Full Name as Reference. Email receipt to email@example.com Make Cheque out to Australian Women in Agriculture Post Cheque to PO Box 7387 Shepparton, VIC, 3632 For all enquiries, email AWiA Treasurer Maria Brown-Shepherd at firstname.lastname@example.org or phone 0407 269 692.