Please enter your name:

Dr.

Please enter the name of your entity.

Entity Name: 
 

Please enter your ABN No.

ABN Number:
 
(If no ABN is supplied we are required to withhold 46.5% tax )

Postal Address of where you would like the cheque sent:

Postal Address:  

Please enter your clinic name:

Clinic Name:  

Payee Name:

Cheque Payable To: 
 

To:

Dandenong Casey General Practice Association
314B Thomas Street
Dandenong  Vic  3175
ABN  52 655 006 834

Details of Meeting Attended:

Date of Meeting:

IN HOURS    OUT OF HOURS

Duration of Meeting:

Fee for Meeting
+ GST
TOTAL

  $    ** Please Note **
  $   Re Fee - we can complete
  $   this for you.
  $