Those who registered will undergo a selection process and all successful candidates will be notified of their acceptance after 20 March 2013. Payments will be required after notification of selection.
DELEGATE DETAILS |
Title
|
First name
|
Surname
|
Company/Organisation
|
|
Male
Female |
HPCSA number (e.g. MP)
|
ID number
|
Current occupation
|
Postal address
|
Country
|
| Work telephone: Code
Number
|
| Fax:
Code
Number
|
| Cell
number
|
Email address
|
Dietary requirements
None:
Kosher:
Halaal:
Vegetarian:
Diabetic
|
COURSE DETAILS |
How did you hear about the course?
|
Professional qualification
If other, please specify
|
In which ONE functional area do you spend most of your working day?
|
WORKPLACE DEMOGRAPHICS |
Select the ONE sector that best describes your main workplace
Select your main area of work
|
Please indicate your affiliation and responsibility (e.g. nursing section, engineer, HIV/AIDS program officer, occupational health, etc.)
|
Professional background
|
Name and contact details of your direct supervisor/coordinator
|
Have you ever before participated in training on non-TB related or TB related infection control? If yes, please specify
|
What are your current tasks and responsibilities in the field of infection control?
|
Explain why you are applying for this course, what you hope to learn from it, and how it will benefit your employer or institution.
|
PAYMENT METHOD AND INSTRUCTIONS |
|
Bank transfer;
Credit card
Only master and visa credits cards are accepted.
- A photocopy of the front and back of the credit card,
- Your credit card expiry date
- The last three digits on the reverse side of the card as well as the cardholder’s identity document or passport must be faxed together with the registration form.
- An authorization letter should also accompany the registration form authorizing the Medical Research Council to deduct all the necessary payments. All information provided will be handled with the strictest confidence.
The organizers will not be responsible for identifying funds if the delegates name and initials are not mentioned. |
BANK TRANSFER/ELECTRONIC TRANSFER |
Account name
Bank
Branch code
Account no
Swift code |
South African Medical Research Council
ABSA Bank
632 005
906 475 8975
ABSAZAJJ |
Please indicate the following references in order for the organizers to confirm your payment:
- Your surname and initials
Please fax proof of payment, to Deon Salomo +27 (021) 938 0238.
|
CANCELLATION & REFUNDS |
Cancellations must be sent in writing to Mr Deon Salomo, South African Medical Research Council. PO. Box 19070, Tygerberg, 7505, Cape Town, South Africa or via fax to +27 21 938 0238. For cancellation before 15 May 2013, a cancellation charge amounting to 25% of the registration fee will be deducted from the refund. No refund for cancellation will be granted for any reason after 15 May 2013. The payment for refunds will be processed after the course. |
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