Nicotine Addiction, Smoking & Vaping Cessation
 Registration Form

Complete the details below to register and pay now for the 3-day online Nicotine Addition, Smoking & Vaping course.
If you have any questions please contact lifestylemedicine@avondale.edu.au.  

Click 'save' at the bottom of the form to return to your registration form at a later time.

Personal Details

Please complete all fields below

Title
Entity Data - Profile - Title
First Name
Entity Data - Profile - First Name
Surname
Entity Data - Profile - Surname
Mobile Number
Entity Data - Contact - Home - Mobile Number
Email Address
Entity Data - Contact - Home - E-mail Address
Current Position / Job Title
Basic - Text
Business / Organization Name
Basic - Text
Department Name (if applicable)
Basic - Text
[Home] Address -
Entity Data - Address
Address - NOTE: If your company is paying for the course, please use the company's address.
Entity Data - Address - Lookup
[Home] Address - Street Address 1
Entity Data - Address - Street Address 1
[Home] Address - Street Address 2
Entity Data - Address - Street Address 2
[Home] Address - Unit/Flat Number
Entity Data - Address - Unit/Flat Number
[Home] Address - Street/Lot number
Entity Data - Address - Street/Lot number
[Home] Address - Street Name
Entity Data - Address - Street Name
[Home] Address - Suburb
Entity Data - Address - Suburb
[Home] Address - Overseas State/Province
Entity Data - Address - Overseas State/Province
[Home] Address - State
Entity Data - Address - State
[Home] Address - Post Code
Entity Data - Address - Post Code
[Home] Address - Country
Entity Data - Address - Country
Digital Signature
Basic - Digital Signature
Date
Basic - Date

Payment

To finalise your registration for this short course please complete your payment via credit card.  A tax receipt will be available for you to access in your portal.  

To get the early bird discount PAY NOW via Credit Card and use the code "EARLYBIRDNASVC". This is only available until the 22nd of July 2024 and for credit card payment.

 
Please note - this is a non-refundable course.  If you are not able to attend on any of the days the course is being delivered, you will have access to the recordings of the course via your learning portal for a limited time. 

Payment Options
Tuition Fees (EARLYBIRD dates:  Up until July 22 $1750, July 23 – August 21 Full price $1999.   course will be:  Thursdays -  August 22, August 29 and September 5) 		$1,999.00
$1,999.00
$0.00
$1,999.00