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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.
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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 __________________________________ PAYMENT DETAILS – CATEGORY – DELEGATE DETAILS – REGISTRATION FORM 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 esau2013@gmail.com
