Child & Adolescent Psychiatry
Registration Form
Are you a member of OTASA?:
Yes
No
OTASA Membership Nr:
Title:
First Name:
Surname:
Organisation:
Cell Number:
Email:
HPCSA Number Nr:
BANKING DETAILS
Account holder: POTS Association
Account number: 62302978624
Branch: FNB Cresta
Branch code: 254905
Reference number: Your initials and surname
PAYMENT DETAILS
Total cost: R 400.00 (OTASA members)
R 500.00 (non-OTASA members)
Discount price available for OTT/OTA
Method of payment: Electronic payment/Bank Deposit
Please send proof of payment and completed registration form to:
Fax: 086 598 7090
Email: potsworkshop@gmail.com
Please make sure that your proof of payment has been received by emailing Catherine Couvaras.
PLEASE NOTE: Payment for the workshop must take place before 20 September 2014 as no
payments will be accepted on the day of the workshop. Please bring proof of payment with on the
day of the workshop for registration purposes. Receipts will be issued on the day of the workshop.