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Glaucoma NZ Professional Education Programme

Title:
First Name:
Last Name:
Occupation:
Practice or Clinic:
Address:
Postcode:
Telephone:
Email:
Verification Code
Type Verification Code Above
Have you previously enrolled with Glaucoma NZ? Yes No
Receipt to be issued in the name of individual or practice/clinic? Individual Practice/Clinic
Fee
$285 (GST inclusive)
Payment options
Direct credit payment to ASB account
GLAUCOMA NEW ZEALAND
12-3013-0180964-00
Date of direct credit:
/ /
Amount paid:
Credit Card
Cheque
Please print out this completed page and post together with your cheque to: Glaucoma NZ, Dept of Ophthalmology, Private Bag 92019, Auckland 1142.
Finally click submit button below to complete transaction.
Please note that all fields are compulsory
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