ONLINE FORM:
Complete the form below and click to SUBMIT. You will be contacted shortly for confirmation.
Please fax your proof of payment to: 011 768 1174
DELEGATE DETAILS:
Title:
Initials:
First Name:
Surname:
HPCSA Number:
Profession:
Cell No:
Tel No:
Fax No:
E-Mail:
Postal Address:
Special Meal Requirements:
Halaal
Kosher
Vegetarian
Other - Please specify:
Registration Category:
Early Bird Registration
(on or before 15 February 2010)
Late Registration
(after 15 February 2010)
Specialists
R2 500.00
R2 800.00
General Practitioners
R2 000.00
R2 300.00
Registrars
R1 500.00
R1 800.00
Nurses, Midwives & Sonographers
R1 300.00
Partners / Spouses
R 350.00
R 500.00
Trade Delegates
R1 000.00
R1 400.00
Day Registration:
Friday 7 May 2010
R1 200.00
Saturday 8 May 2010
Sunday 9 May 2010
R 800.00
Half Day Pre-Congress Workshops:
6 May 2010
Will be held form 08h00 - 17h00 at Universitas Hospital
Please note that the workshop is limited to 50 delegates only
Basic Ultrasound Workshop
R 600.00
R 700.00
Social Functions - Please indicate your attendance:
Cocktail Function (7 May 2010)
R 000.00
(included in registration fee)
Yes, I will attend the cocktail function
No, I will not attend the cocktail function
Gala Dinner (8 May 2010)
R 200.00
Yes, I will attend the gala dinner
No, I will not attend the gala dinner
For further comments or additional information :
Comments
Click here to print out the Registration Form
Please fax it to: 011 768 1174 with proof of payment.
Payment Details:
Direct deposits (credit card payment is not accepted) Name of Account: SASUOG 2010 CONGRESS Bank: ABSA BANK Account No: 4073157830 Branch code: 632005
Direct deposits (credit card payment is not accepted)
Name of Account: SASUOG 2010 CONGRESS
Bank: ABSA BANK
Account No: 4073157830
Branch code: 632005
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