Surgery Update

Saturday28thto Sunday 1st March 2015

KramerBuilding, Middle Campus, University of Cape Town

Registration Form

Delegate Information:

Title:ProfDrMrMrsMsMissOther

Surname/Family name:
First/Given name: / Initials:
Organisation:
Department/Section: / HPCSA Reg No:
Designation:
Full Postal Address: /
Contact Numbers: / Country /
City code: / Telephone No: / Fax No:
Cellphone No: / E-mail address:

Conference Registration:

Categories / Early Registration / Late Registration
Up to 23 Jan 2015 / From 23 Jan 2015
Full congress / R1700 / R1950
Registrars / R800 / R950
Daily Fee / 1000 / 1200
Conference Fees include: Teas, Lunch and Registration Materials
If attending on a daily basis, please indicate which days you will be attending / Sat / Sun

Total Conference Registration Fee:

Dietary Requirements:

Vegetarian / Halaal / Kosher / Other

Payment Information:

Bank Account Details / Payment Method
Bank / Standard Bank / Bank Deposit / Internet Transfer
Branch / Mowbray
Branch Code / 024909 / Cheque / Credit Card
Account Holder / Conference Management 04
Account Number / 071 291 121 / Cancellations
Cancellations should be made in writing and mailed, faxed or e-mailed to Deidre Raubenheimer at the address below.
A 10% cancellation fee applies before 23 January 2015 – thereafter a 100% cancellation fee will apply.
Swift Code / SBZAZAJJ
UCT Fund Number / 202012
Cost Centre / MPG1004
*Please note that we do not accept foreign cheques. / *Proof of payment should be sent to +27 21 650 1926.
*Please note that all bank charges are for your OWN account

Cancellation;

PLEASE RETURN THIS FORM TO:Deidre Raubenheimer, Conference Management Centre, UCT Faculty of Health Sciences, Anzio Road, Observatory 7925TEL: (021) 406 6330 / FAX: (021) 650 1926/ EMAIL: Deidre.Raubenheimer @uct.ac.za