South African Immunological Society Conference - UCT

University of Cape Town 1992 MBChB 25th Class Reunion 08-10 December 2017

Venue: Faculty of Health Sciences, Bernard Fuller Building, Anzio Rd, Observatory

REGISTRATION FORM DELEGATE INFORMATION: Title:

Prof Dr

Mr

Mrs

Ms

Miss Other:

Surname: First Name:

Initials:

Place of Employment: Actual Job Description: Degrees: Full Postal Address: Contact Numbers:

Code: Country /

Telephone No:

City code:

Cellphone No:

Fax No:

E-mail address:

Name of Partner Attending:

REGISTRATION FEES: (Registration Fees includes, registration, materials, cocktail event, presentations, campus tours, gala dinner. Ex tra drinks at gala dinner and all Sunday event costs for ow n account. Any surplus will be donated to the UCT in Eden project.): DELEGATE: R2,000 PARTNER: R800 TOTAL: AAAAAAA DIETARY REQUIREMENTS: PLEASE NOTE THAT WE USE HALAAL FRIENDLY CATERERS ALWAYS  Vegetarian

 Halaal (STRICTLY)

ACCESSIBILITY REQUIREMENTS  Large print  Will an assistant be (documents) accompanying you?

 Kosher (STRICTLY)

 Other (please specify)

 Wheelchair

 Other (please specify)

PAYMENT INFORMATION:

Bank Account Details Standard Bank of South Africa Riverside Centre, Main Road, Rondebosch7700, South Africa Branch Code 125009 Account Holder UCT Sundries Account Account 07 150 3854 Number Swift Code SBZAZAJJ Bank Branch

 Bank Deposit

PAYMENT METHOD  Internet Transfer

 Cheque

PLEASE USE AS REFERENCE: “FHS 1992 Reunion / Fund No: 120098”. *Proof of payment should be e-mailed to Linda at [email protected] *Please note that we cannot accept foreign cheques. *Please note that all bank charges are for OWN account

Please return this form to: Linda Rhoda, Manager: Marketing & Communications, Dean’s Office, Barnard Fuller Building, Anzio Road, Observatory 7925. Tel: +27 21 406 6685. Email : [email protected]