compulsory fields * 

PLEASE NOTE: On-site registrations will be charged late registration fee + 10%

PERSONAL DETAILS:

Title

 * 

First Name

 * 

Surname

 * 

Preferred Name

Telephone Number

 * 

Fax Number

Mobile Number

 * 

Email

 * 

Confirm Email

 * 

HPCSA Number

 * 

Name of Hospital/ Company/ Organisation

(Please exclude any apostrophes in names)    

Postal Address

City

Postal Code

Region / Province

 * 

Food Allergies/Special Instructions?

Profession

 * 

ACCOMPANYING PERSON TO SOCIAL FUNCTIONS:

Title

First Name

Surname

Food Allergies/Special Instructions?

Social Functions

 

REGISTRATION INFORMATION:

Registration Type

Early Registration

(Before 7 May)

Late Registration

(8 May – 9 July)

 

Doctor Members

 R 2 300.00

 R 2 800.00

Doctor Non-Members

 R 2 500.00

R 3 000.00

Nurses, Registrars & Allied Medical

 R 1 500.00

R 1 800.00

Day Registration
(Excludes Social Functions)

  R 1 500.00

 R 1 500.00

 

TRADE:

Additional Trade Members

 

 R

1 500

PAYMENT:

Note: If registering as a group, EACH PERSON must complete a separate registration from. This booking is non-transferable, for any changes please email,

[email protected]. Only full prepaid registrations will be accepted by the organisers.

METHODS OF PAYMENT: Please fax through proof of payment to

+27(0)11 463 3265 or email to

[email protected]. Should this not be received, your booking will be invalid. Please select your method of payment below.

 

Government purchase orders:

Please note: No Government Purchase Orders will be accepted. All registrations must be prepaid.

Bank Deposit or EFT

 

 

Credit Card

   

TOTAL:

COMMENTS:

 

CANCELLATION POLICY:

Registration fees will be refunded less 10%

administration fee. Cancellations must be

submitted in writing no later than 15 June 2012. No cancellations will be

received after this date.

 

**Sum of

7 + 3

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