Registration Form
 

Registration will only be confirmed once proof of payment has been received.

A registration cancellation fee of 15% will be levied on the cancellations of Confirmed Registration within 7 days of Course date.

5% registration cancellation fee for cancellations more than 7 days prior to course.

50% cancellation fee for delegate non-attendance.

 

Name
Surname
ID Number
E-mail address
Telephone(W)
Course Title: Please select a course
Date of Course:
Delegate: Title
Delegate: Name
Delegate: Surname
Delegate: e-mail
Delegate: Tel no
Delegate: Fax
Delegate: Region (Johannesburg/Cape Town/Durban)
Research Position:
Years Experience:
Therapeutic Area:
Have you attended a course run by AGCP previously?

If yes, which one and when?
Invoice to be addressed to:
Vat Number:
Invoice Postal address (full) plus tel & fax:
E-LEARNING COURSE: Postal address (full) for delivery of CD
Where did you hear about the AGCP Course?

Payment Details: (AGCP VAT #: 4780207835)
Please make a direct payment into our account and then fax your proof of payment to:

Attention:

Savi Chetty-Tulsee

Fax: 086 684 2997
 
 

The Deposits can be made into the following account:

BANK:

Standard Bank

ACCOUNT NAME:

AGCP

ACCOUNT NUMBER:

022681566

ACCOUNT TYPE:

Current

BRANCH:

Sandton

BRANCH NUMBER:

01920590

REFERENCE:

Delegate's Surname

VAT NUMBER:

4780207835