| CORRESPONDENCE ADDRESS |
| Organisation |
|
Address
|
|
| City |
|
| Postal code |
|
| Country |
|
| Full name |
|
Work telephone:
Country
Code
Number
|
Fax:
Country
Code
Number
|
| E-mail address |
|
| VAT registration number |
|
| INVOICING ADDRESS |
| Organisation |
|
Address
|
|
| City |
|
| Postal code |
|
| Country |
|
| Full name |
|
| Work telephone |
Country
Code
Number
|
| Fax |
Country
Code
Number
|
| E-mail address |
|
| VAT registration number |
|
| COMPANY'S REPRESENTATIVES |
| First name |
|
| Surname |
|
| Work telephone |
Country
Code
Number
|
| Fax |
Country
Code
Number
|
| Mobile |
Country
Code
Number
|
| E-mail address |
|
| STAND |
| Stand unit price: |
R7 000 |
| Number of stands required |
|
| |
Note: Discount will apply for additional stands. |
First preference
|
|
| Second preference, if first is not available |
|
| Total R |
|
| PAYMENT METHOD |
|
Bank transfer;
Credit card |
Only master and visa credit cards are accepted. We also need:
- a photocopy of the front and back of the credit card, so that the card number, expiry date and the CVV (last three digits on the reverse side of the card) are clearly legible
- the cardholder’s identity document or passport, faxed together with the Registration Form
- an authorisation letter to accompany the registration form, authorising the Medical Research Council to deduct all the necessary payments.
All information provided will be handled with the strictest confidence. The organisers will not be responsible for identifying funds if the delegate’s name and initials are not mentioned.
|
| Bank transfer/electronic transfer |
Account name
Bank
Branch code
Account no |
South African Medical Research Council
ABSA Bank
632 005
906 475 8975 |
Please indicate the following references in order for the organizers to confirm your payment:
- Your surname and initials
Please fax proof of payment, to Meagan Simpson +27 (021) 938 0238.
|
| EXHIBITION INFORMATION REQUIRED FOR PROGRAMME BOOK |
Company description
No more than 50 words
|
Web site
|
Contact details to be published in programme book
|
Please attach your company logo
|
|
| |
