Fertility Expert Forum 2019
SASREG in Collaboration with Merck Fertility Expert Forum 2019

Registration Form

To register, kindly complete one form per delegate.

DELEGATE INFORMATION

*Title: *Last Name:
*First Name:
(for badge)		 Nationality:
HPCSA Number: *Organisation/Institute/Trust:
This is my:
(please select)		 Private Address
Institution Address		    
Address: City:
State/Province: ZIP/Post Code:
Country:
Work/Business Telephone Number:
(Country code/city code/number)		 Fax:
(Country code/city code/number)
*E-Mail: *Verify E-Mail:
Mobile/Cell Number:
Special Dietary Requests:
Vegetarian: Yes / No / Other If other, specify:
Other Requests
Other Special Requests:
(Please specify any access needs you have e.g. wheelchair user, mobility difficulties, hearing impaired etc.) 		   
*Compulsory fields.

REGISTRATION
Category
Cost per person
Quantity
Amount
Specialist Delegate
R 1 000.00
Embryologist Delegate
R 500.00
Nurse Delegate
R 300.00
Student Delegate
R 300.00
TOTAL: A - Registration
DINNER BOOKINGS
Category
Cost per person
Quantity
Amount
Delegate Dinner 6 September
R 0.00
Delegate Dinner 7 September
R 0.00
Accompanying Person Dinner 6 September
R 250.00
Accompanying Person Dinner 7 September
R 350.00
TOTAL: A - Dinner

A - ACCOMMODATION

Accommodation will be at the Capital on the Park, Sandton. Full pre-payment for your accommodation will be required in order to confirm the booking. All incidentals to be settled directly with the hotel prior to check out. 100% Cancellation Fees will be charged should you cancel once reservation has been confirmed.

Single Occupancy - R1600.00 per room per night
Double Occupancy - R1845.00 per room per night

Arrive Date: Depart Date:
No. of Nights:
Name of Person Sharing Room (if Applicable) Name and Age of Children (if Applicable)
Special Dietary Requests:
Vegetarian Meal, etc.		 Special Hotel Requests:
e.g. Non Smoking Room, Physically Disabled etc.

Hotel Name Location,
Distance &
Transportation		 Room Type
Room
Rate
  
Total
Capital on the Park Sandton SINGLE
Single Occupancy
1 600,00
DOUBLE
Double Occupancy
1 845,00
TOTAL: A - Hotel Accommodation
TOTAL: A - Hotel Deposit

TOTAL AMOUNT PAYABLE

I, the undersigned, do hereby authorise Turners Conferences to debit my credit Card for the following amounts:
(please fax a copy of the front and back of your credit card to Turners Conferences)

A Registration
C Dinner
B Accommodation (Deposit)
GRAND TOTAL:

PAYMENT DETAILS
Please select your payment option below.

Option 1
Bank transfer
You must specify your Name & Surname & FERTILITY as reference on your payment. Forward to:
Account Name:Turners Conferences and Conventions Pty Ltd - FERTILITY 2019
Bank:ABSA Bank
Account No.:4060455419
Branch:KZN Business Banking
Branch Code:632005
Swift No.:ABSA-ZA-JJ
(Please fax a copy of your transfer to Turners Conferences +27 31 368 6623)
Final date for bank transfers will be the 24th August 2019.
Special Note:
All fees associated with FOREX Payments are for the delegates own account. It is the responsibility of the delegate to advise their bank when processing payment via bank transfer. Turners nor the event will be held liable for bank fees relating to payments.
Option 2
Credit Card
When opting to process payment by credit card, further instructions will be emailed advising on how to process payment via a secure online 3D PayGate portal. A unique reference number will be issued to you.

Please complete this booking form and submit it to the Turners Conferences:

Turners Conferences and Conventions (Pty) Ltd
PO Box 1935, Durban, 4000 South Africa
Telephone: +27 31 368 8000
Fax: +27 31 368 6623
Email: Gills@turnersconferences.co.za

All transactions are conducted in terms of Turners Conferences standard conditions of trading. They are published on the Turners Conferences website & available on application.
Without the complete documents, we are unable to process your booking.

Your booking will only be confirmed once payment has been received.

Type this number into the box alongside: