/ IISA INSURANCE FORUM
A MARKET REVIEW AND ECONOMIC OUTLOOK
Wednesday, 7 October 2015 from 08h00 to 12h00
The Sandton Indaba Hotel, William Nicol Drive, Fourways, Gauteng

single delegate registration

section 1 / personal details
Surname: / Initials: / Title (Mr/Dr/Mrs):
First Names:
*ID No: / IISA Pin:
Employer:
Postal Address:
Company Vat no:
Mobile No: / E-mail:

* For IISA Continuous Professional Development hours allocation purposes

section 2 / Payment Details & Declaration

Mark registration type and optional extras with X:
IISA Corporate Members
Non Member
Paid up IISA Professional Members
Retired IISA Member
Kosher Surcharge
Halaal Surcharge
Finger Breakfast will be served / Ex. Vat Incl. Vat
R307.02 R350.00
R491.23 R560.00
R263.16 R300.00
Complimentary
R394.74 R450.00
R307.02 R350.00
Direct Deposit. NB: Invoice and IISA banking details will be sent upon receipt of registration form ** Payment due on presentation of invoice**.
Invoice PIN to be used as deposit reference.
Please debit my credit card: / Visa / Master / Amex
Credit Card number:
Name on Card:
Expiry Date: (mmyy) / CVC Code (Last 3 number on reverse side of card):
Payment Option: / Straight / Budget: ….…. Months
DECLARATION:
I understand that submitting this form constitutes a registration for the above event. I acknowledge that the Insurance Institute of South Africa does not refund or substitute any fees paid for events and that I will remain liable for payment if I do not cancel the registration in writing before 1 October 2015 or if I fail to attend the event without having cancelled the registration within the stipulated period.
USE OF YOUR PERSONAL CONTACT INFORMATION
Your consent is requested to use your personal contact information (email address, and name and company) to receive News@IISA and other industry information. YES / N0
Signature: / Date: …….… / ….…… / 2015

R.S.V.P. by 1 October 2015

Please note that venue capacity is limited and seats will be allocated upon receipt of completed registration form only on a first come first served basis.

Please send completed form to:

Fax: 0861 01 4472 | E-mail: