Registration

compulsory fields * 
PERSONAL DETAILS:
Title  * 
Initials: * 
First Name  * 
Surname  * 
Telephone Number  * 
Fax Number
Mobile Number  * 
Email  * 
HPCSA Number  * 
Postal Address
City
Postal Code
Special Dietary Requirements
(please note that the food at the ELICC is halaal friendly)
PARTNER'S DETAILS: (for social function only)
Title
First Name
Surname
Special Dietary Requirements
Partner / Spouses
(For social functions only) 		  R 550
PROFESSION:
Profession
Other:
   
   
 
PRE-CONGRESS WORKSHOP (Thursday 19 July 2012):
Applied Science  R   700.00  Not Attending
Cardiology Update for the Generalist  R   350.00  
Cardiac Imaging  R   700.00  
Allied Professionals  R    350.00  
Paediatric Cardiology "Tetralogy of Fallot - from child to adult"  R    700.00  
 
REGISTRATION INFORMATION:
Registration Type Early Registration
 Late Registration
(from 1 April 2012)
 
SA Heart Association - Full Member ( Cardiologists, Physicians, Surgeons)  R 3 600.00  R 4 300.00
SA Heart Association - Associate Member (Allied Professionals)  R 2 600.00 R 2 800.00
PASCAR Member (Members outside South Africa)  R 2 600.00  R 3 300.00
Non SA Heart Member - (Cardiologists, Physicians, Surgeons, General Practitioners)  R 4 500.00  R 5 300.00
Non SA Heart Member (Allied Professionals, Nurses, Technologists, etc)
 R 2 900.00 R 3 300.00
     
Invited Speaker (Local & International)  R          00  R         0
Registrars  R 2 600.00  R 2 800.00
Basic Scientists  R 1 800.00  R 2 000.00
Daily Registration   R 2 100.00  R 2 400.00
 
TRADE:
Trade x2 free registrations per stand. All additional trade:
    R 3 000
SOCIAL FUNCTIONS: (Please complete the following)
Cocktail Function (Thursday 19 July 2012)   R       0
SA Heart Congress Dinner (Friday 20 July 2012)   R   350
PAYMENT:
Bank Deposit or EFT
Credit Card

   
TOTAL:
 
**Sum of 6 + 7 ?
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