CONTACT DETAILS: (All Blocks Must Be Completed)

CONTACT DETAILS: (All Blocks Must Be Completed)

DELEGATE REGISTRATION FORM: MMIRA2017

CONTACT DETAILS: (All blocks must be completed)

Title: / Initials: / Surname:
Name to be used on name tag (first name and surname):
Institution: / School/Department
Invoice address postal:
City: / Postal code:
Institution street address:
City: / Postal code:
Tel: / Fax:
E-mail address: / Cell:
Company / Institution VAT Number:
Please indicate special dietary requirements:
Do you intend to present? (Mark with an X) / Yes / No
Abstract number:(If applicable)
Do you intend to display books/exhibit? (Mark with an X) / Yes / No
NB: Do you give permission for your contact details (Institution and email address) – apart from your name – to be included on the list of delegates? (Mark with an X) / Yes / No

REGISTRATION (Please tick appropriate block with X:)

Please take note: The registration fee includes registration, conference material, refreshments and lunch during the day(s) of attendance, gala dinner, but excludes all travelling costs, accommodation,and any other refreshments not included on the programme.

Registration: Delegates Full Conference
(1) Register for attendance before 22 June 2017
(2) Pay the registration fee before 21 July 2017 / R4500.00
Registration: Post-graduate Students
(1) Register for attendance before 22 June 2017
(2) Pay the registration fee before 21 July 2017 / R3500.00
Registration: Delegates 1 Day only
(1) Register for attendance before 22 June2017
(2) Pay the registration fee before 21 July 2017 / R2000.00

1 DAY ATTENDANCE(Please tick appropriate block with X)

30 August 2017 / 31 August 2017 / 1 September 2017

EVENING FUNCTIONS– INCLUDED IN THE REGISTRATION FEE FOR DELEGATES FOR THE FULL CONFERENCE AND 1 DAY ATTTENDANCE – BUT PLEASE INDICATE WHETHER YOU (AND YOUR PARTNER) WILL BE ATTENDING (X)

COST / ATTENDING?
Tuesday Dinner – (Delegate) 31 August 2017 / R0.00
Dinner - (Partner) 31 August 2017 / R250.00
TOTAL DUE (registration, partner dinner)

REGISTRATION PROCEDURE:

  1. Complete form and submit to conference administrators.
  2. An official invoice, with banking details, will subsequently be e-mailed to you to confirm your successful registration.
  3. To confirm your attendance kindly deposit the applicable fee directly into the bank account (as indicated on the invoice) – either by bank deposit or electronic transfer, and fax or e-mail a copy of the deposit slip/proof of electronic transfer to Petra or Bronwyn Lawson at:

Fax: 086541 1173

E-mail:

Please send your proof of payment on the same day the deposit is made.

  1. It is your responsibility as delegate to ensure that the correct payment is made and that proof of payment is sent to the Conference Administrators, Petra and Bronwyn Lawson.

REFUND POLICY

No refunds but you are most welcome to send a substitute. Please inform the conference administrator

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Office use only:

Amount payable: / Invoice Number:
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