UNIVERSITY OF CAPE TOWN
Department of Obstetrics & Gynaecology

CTG WORKSHOP
11, 13, 16, 18, 20 and 25 November 2015
Department of Obstetrics & Gynaecology, University of Cape Town

REGISTRATION FORM

To register, kindly complete one form per delegate.

SECTION 1: Delegate Information

Title: Last Name:
First Name (for badge): MP Number:
This is my: Private Address
Institution Address
Institution Name:
Address: City:
State/Province: ZIP/Post Code:
Country:
Telephone:
(Country code/city code/number)
Fax:
(Country code/city code/number)
E-Mail: Mobile/Cell Number:
Please advise if you would like to include your name and email address to the delegate pack: Yes /No
Registration Code: For office use only
Please advise if you require transport to UCT: Yes /No
Dietary Preferences
Vegetarian: Yes /No /Other If other, specify:

REGISTRATION FEES: CTG Workshop

Registration Fees - South African Rand (ZAR) Only (includes VAT)

Registration Category
Cost
(Per day)
No. of
People
Amount
(ZAR)
Standard Delegate & Privately Employed Midwife Registration: (1 Day Workshop)
650
State Employed Midwife Registration: (1 Day Workshop)
400
Registrar Delegate Registration
400
Please indicate the date you would like to attend by ticking the box applicable:
Wednesday 11th Nov  
   
Friday 13th Nov  
   
Monday 16th Nov  
   
Wednesday 18nd Nov  
   
Friday 20th Nov  
   
Wednesday 25th Nov  
   
TOTAL: Registration Fees - CTG Workshop

Registration fees Include: Attendance at the workshop on the specific day your register for, tea breaks, lunch, a badge and a printed programme.

Cancellation Fees: Please notify the Secretariat in writing of any cancellations, all approved refunds will be issued after the course. An administration fee of 10% will be charged for all cancellations received before 24 September 2013. Please note that no refunds can be made for cancellations made after 24 September 2013.

TOTAL AMOUNT PAYABLE

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

GRAND TOTAL: Registration Fees - CTG Workshop

PAYMENT DETAILS

Please select your payment option below.

Option 1
Bank Transfer
You must specify your name and the words "O&G CTG Workshop" on your bank transfer. Forward to:
Account Name:Turners Conferences & Convention Pty Ltd
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 Transfer payments will be the 6 November 2015.
Option 2
Credit Card
Please complete the following authorisation for Congress Organisers to debit your credit card.
A clear photocopy of both sides of the credit card is required for bank approval and verification

Credit Card Type:
Credit Card Number
Expiry Date
Cardholder's Name
3 Digit no. on reverse side where applicable

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

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

Type this number into the box alongside: