Transcript Slide 1

PAYMENT DETAILS – CATEGORY – DELEGATE DETAILS –
REGISTRATION FORM
UROLOGY NURSING
WORKSHOP
PLEASE NOTE THAT NO REGISTRATIONS WILL BE
CONFIRMED WITHOUT A COMPLETED REGISTRATION
FORM ACCOMPANIED BY PROOF OF PAYMENT!
PLEASE FAX / EMAIL COMPLETED REGISTRATION FORM &
PROOF OF PAYMENT TO HILDA ON FAX 086 211 7783
EMAIL: [email protected]
Title: ___________ Initial: _____________ Full Name: _______________________________
HPCSA No: _________________________ Surname: ________________________________
Tel No: _____________________________ Fax No: _________________________________
Cell No: ____________________________ E -mail: _________________________________
From witch hospital:___________________________________________________________
Department / Ward ___________________________________________________________
Special meal requirements: _____________________________________________________
REGISTRATION CATEGORY:
NURSING UROLOGY
Registration fee
R300.00
TOTAL PAYABLE
R300.00
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 / 9 OR EMAIL [email protected]