PHASA 2010 Conference

East London

29 November - 1 December 2010

Registration form

This registration form serves as a tax invoice. A tax invoice/receipt will be issued after payment has been received/identified. One form per delegate is required.

DELEGATE DETAILS
Title
First name
Surname
Company/Organisation
Postal address
Country
Work telephone  Code Number
Fax  Code Number
Email address
Dietary requirements
None:     Kosher:     Halaal: Vegetarian: OR

Other:
Please tick if you wish to become a PHASA member

PHASA membership for 2011 is included in your registration fee (January - December 2011)

Choose a workshop(s) from the list below:
REGISTRATION FEES                Check currency here

Late registration
R3 200 - Delegate
R2 000 - Student (Fax your student card to +27 (021) 938 0238)
Student no:

Total payment:


R

Registration is inclusive of the social event
PAYMENT METHOD AND INSTRUCTIONS

Bank transfer;    Credit card

Only master and visa credits cards are accepted. We also need a fax of:

  • a photocopy of the front and back of the credit card, so that the card number, expiry date and the CVV (last three digits on the reverse side of the card) are clearly legible
  • the cardholder’s identity document or passport
  • an authorisation letter, authorising the Medical Research Council to deduct all the necessary payments. 

All information provided will be handled with the strictest confidence. The organisers will not be responsible for identifying funds if the delegate’s name and initials are not mentioned.
BANK TRANSFER / ELECTRONIC TRANSFER

Account name
Bank
Branch code
Account no

South African Medical Research Council
ABSA Bank
632 005
906 475 8975

Please indicate the following references in order for the organizers to confirm your payment:

  • Your surname and initials
  • Please fax proof of payment, to Meagan Simpson +27 (021) 938 0238.
CANCELLATION & REFUNDS
Cancellations must be sent in writing to Meagan Simpson, South African Medical Research Council. P. O. Box 19070, Tygerberg, 7505, Cape Town, South Africa or via fax to +27 21 938 0238. For cancellation before 29 October 2010 a cancellation charge, amounting to 25% of the registration fee will be deducted from the refund. No refund for cancellation will be granted for any reason after 29 October 2010. The payment for refunds will be processed after the conference.