Registration Form

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PAYMENT DETAILS – CATEGORY – DELEGATE DETAILS – REGISTRATION FORM
PLEASE NOTE THAT NO REGISTRATIONS WILL BE CONFIRMED
WITHOUT A COMPLETED REGISTRATION FORM ACCOMPANIED BY
PROOF OF PAYMENT!
PLEASE FAX COMPLETED REGISTRATION FORM & PROOF OF
PAYMENT TO HILDA ON FAX 086 607 0026
Title: ___________ Initial: _____________ Full Name: ________________________________________________
HPCSA No: _________________________ Surname: _________________________________________________
Tel No: _____________________________ Fax No: __________________________________________________
Cell No: ____________________________ E -mail: __________________________________________________
Hospital Working in:___________________________________________________________________________
Diet Required: Halaal ___________ Vegetarian ____________ Normal __________________________________
Registration Category
Yes / No
Cost
19 Sept – Laparoscopic Skill W/shop + skill
surgeries @ Pretoria Urology Hospital
R100
19 Sept – Ultrasonography skill & related
surgeries @ Steve Biko Hospital
R100
Dinner 19 Sept (Partner is welcome) Please
let Hilda know
R100 – PER PERSON
Workshop CSSR 20 Sept
R500
Dinner 20 Sept @ CSSR (Partner is welcome)
Please let Hilda know
R100 – PER PERSON
Live Surgery 21 Sept
R100
After Live Surgery 21 Sept @ 18h00 Cocktail
Greeting Drinks
R50
PLEASE NOTE THAT NO CREDIT CARD FACILITIES ARE AVAILABLE!!
BANKING DETAILS:
NAME OF ACCOUNT
: PRETORIA UROLOGY HOSPITAL (PTY) LTD
BANK
: ABSA
ACCOUNT NO
:104 102 0659
BRANCH CODE
:Sunny Side – 8082
REFERENCE
: Your cell no
FOR MORE INFORMATION PLEASE CONTACT
HILDA ENGELBRECHT ON 012 342 3698 OR
EMAIL [email protected]
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