Centre for Diabetes and Endocrinology (Pty) Ltd
Reg. No. 1994/001693/07
81 Central Street, Houghton Estate, 2198
Telephone: 011 712-6000
PO Box 2900, Saxonwold, 2132
Fax: 086 247 0674
Name of Cardholder
Amount to be deducted
Transaction Reference No.*
* See your ‘Confirmation of Booking’ e-mail
Type of Credit Card (Tick box to right of Logo)
The CDE 5 Day
Advanced Course in
Diabetes Care for
Health Care
Professionals
Please
complete
the
following for manual credit
card authorisation and
fax to
086 247 0674
Credit Card Number
Expiry Date (mm/yyyy)
Security Number (Last 3 Digits on back of Card)
Signature of Cardholder
Date
dd/mm/yyyy