Please Print This Form And Send It And Payment To The Address Below

Name:

Title:

Organisation:

Address:

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

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The program lists the title, name and institution (or address) of the licensee being the person responsible for confidentiality.

Licensee (Title, Name and Institution or Address (80 characters):

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Cost
New licensees: AUD$770 (includes GST)

Payment can be made by cheque or credit card

Cheques to be made payable to
WHO Collaborating Centre

Return cheque and order form to
WHO Collaborating Centre, 299 Forbes Street, Darlinghurst, NSW, 2010, Australia

Credit card details (Visa or Mastercard only)

Type of card

____________________________________________________________________

Name on card

____________________________________________________________________

Card Number

____________________________________________________________________

Expiry date

____________________________________________________________________

For further details regarding ordering the CIDI, please Contact Us.

Edited by Gavin Andrews MD, UNSW
©2010 CRUfAD /iw