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Registration form (Basic)

Delegate Details

Title:
Initials:
Surname:
First Name:
HPCSA Registration No.:
Home Address:
Postal Code:
Contact Cellphone:
Telephone (work):
Fax (work):
E-mail:
Special Needs:
Special Dietary Requirements:
Involvement in Peer Help Programmes (Previous or Intended):

Institution/Company Details (for invoice purposes)

Name of company/institution:
Contact person:
Contact e-mail:
Postal address:
Postal code:
VAT number:
Order Number:
Should your institution not provide an order number, written proof from your institution will be required for conference attendance (please enter “0000” in this case)
Telephone number & area code:
Fax number & area code:
Any additional information:

CANCELLATIONS/REFUNDS

Fees are not refundable unless cancellation has been made at least 14 days prior to seminar/training workshop commencement.

Tel: +27 (0) 41 504 1111

Fax: +27 (0) 41 504 2574 / 2731

Email: info@mandela.ac.za

PO Box 77000, Nelson Mandela University

Gqeberha, 6031, South Africa

Connect@Mandela

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