PLEASE NOTE: On-site registrations will be charged late registration fee + 10% |
PERSONAL DETAILS:
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Title
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*
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First Name
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*
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Surname
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*
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Preferred Name
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Telephone Number
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*
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Fax Number
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Mobile Number
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*
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Email
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*
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Confirm Email |
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* |
HPCSA Number
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*
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Name of Hospital/ Company/ Organisation
(Please exclude any apostrophes in names)
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Postal Address
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City
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Postal Code
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Region / Province |
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*
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Food Allergies/Special Instructions?
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Profession |
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*
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ACCOMPANYING PERSON TO SOCIAL FUNCTIONS:
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Title
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First Name
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Surname
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Food Allergies/Special Instructions?
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Social Functions |
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REGISTRATION INFORMATION:
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Registration Type
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Early Registration
(Before 7 May)
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Late Registration
(8 May – 9 July) |
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Doctor Members |
R 2 300.00
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R 2 800.00
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Doctor Non-Members
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R 2 500.00
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R 3 000.00 |
Nurses, Registrars & Allied Medical |
R 1 500.00 |
R 1 800.00 |
Day Registration (Excludes Social Functions)
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R 1 500.00
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R 1 500.00 |
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TRADE:
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Additional Trade Members
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R
1 500
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PAYMENT:
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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.
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Bank Deposit or EFT
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Account Name:
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ALLSA Conference Account
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Bank:
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Standard Bank
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Account No:
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270588361
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Branch Code:
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025009 (Rondebosch)
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NOTE: Please indicate SURNAME and INITIAL on
Bank/Electronic transfers. The Organiser will not be
responsible for identifying funds if the delegate’s name
is not mentioned. The Organiser will not accept any
bank charges associated with the transfer. |
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Credit Card
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The cardholder must complete and sign this form authorising
Sue McGuinness Communications on behalf of
ALLSA Congress 2012 to debit his/her credit card. For security reasons, a photocopy of the front and back of the credit card, as well as
the cardholder’s identity document or passport must be faxed together with the Authorisation Form. Only Visa and Mastercard accepted
Click here to download the Credit Card Authorisation Form
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TOTAL:
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COMMENTS: |
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CANCELLATION POLICY:
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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.
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Anti Spam
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