Delegate Registration Form - SADA

Delegate Registration Form
SADA Congress 1 Nov - 3 Nov 2012
The South African Dental Association
SADA2012
Presents:
Dental dignity for all
Congress & Exhibition
1 Nov - 3 Nov 2012
Register online at www.sada.co.za or fill in registration form and fax to: (011) 642 5718
Section A
PERSONAL INFORMATION
Please print in block capitals and indicate the appropriate blocks with ‘X’.
Surname
REGISTRATION SECTION (MARK WITH ‘X’)
DENTAL CATEGORY fULL REGISTRATION: 1 NOV - 3 nov 2012 DAY DELEGATE REGISTRATION FEES
EARLY BIRD
(BEFORE 17 SEPT)
MARK X
LATE
(AFTER 17 Sept)
MARK X
EARLY BIRD
(before 17 Sept)
1 NOV 2 NOV 3 NOV LATE
(AFTER 17 Sept)
SADA MEMBER R 3 420.00 R 4 104.00 R 1 710.00 R 2 052.00
NON-SADA MEMBER R 4 900.00 R 5 850.00 R 2 450.00 R 2 925.00
DENTAL THERAPIST R 3 420.00 R 4 104.00 R 1 710.00 R 2 052.00
APSA MEMBER R 3 420.00 R 4 104.00 R 1 710.00 R 2 052.00
SASP MEMBER R 3 420.00 R 4 104.00 R 1 710.00 R 2 052.00
ORAL HYGIENIST R 1 596.00 R 1 915.20 R 798.00 R 957.60
DENTAL ASSISTANT R 1 197.00 R 1 436.40 R 598.50 R 718.20
DENTAL TECHNICIAN
(DAY DELEGATE - FRI 2 NOV)
STUDENT:
UNDER GRADUATE
STUDENT:
POST GRADUATE
Complete the entire registration form and return it with your payment/proof
of payment to SADA on Fax no: 011 642 5718, by post to: SADA, Cape
Town Congress 2012, Private Bag x1, Houghton, 2041, or by e-mail to
congress@sada.co.za. Telephonic enquiries: 011 484 5288. Office hours
Monday to Friday 08:00 - 16:00.
FIRST name
ID NR initials Title
Name on badge
Name of Practice/
Academic Institution
POSTAL ADDRESS
hpcsa NR (not practice nr)
Telephone NR (W) - - Cell PHONE nr - -
e-MAIL
FAX NR - COMPANY VAT NR
ACCOMPANYING PERSON
(Also see Section D)
Surname initials Title
Section B
REGISTRATION FEES (VAT INCLUDED)
Registration fees include entrance to all lectures, the exhibition area, all teas and lunches for delegates. Please note: 25% cancellation fee will
be levied for all cancellations made on or before 8 October 2012. No refunds will be given for cancellations received after this date.
R 3 420.00 R 4 104.00 R 1 710.00 R 2 052.00
R 997.50 R 1 197.00 R 498.75 R 598.50
R 1 596.00 R 1 915.20 R 798.00 R 957.60
Code
1 NOV 2 NOV 3 NOV
TOTAL R TOTAL R
TOTAL SECTION B
R

Delegate Registration Form
SADA Congress 1 Nov - 3 Nov 2012
The South African Dental Association
SADA2012
Presents:
Dental dignity for all
Congress & Exhibition
1 Nov - 3 Nov 2012
Register online at www.sada.co.za or fill in registration form and fax to: (011) 642 5718
Section C: CHARITY GALA DINNER*
Please indicate whether you will be attending the Gala dinner by
marking the appropriate block
VENUE: Westin Grand Hotel
DRESS CODE: Smart Casual
Section D: LUNCHES (Accompanying person)
Accompanying person may join a delegate for Teas and Lunches only at a cost
of R490 per day (NOTE: No children U/18 are permitted in the trade exhibition)
YES NO THURS 1 NOV FRI 2 NOV SAT 3 NOV
DELEGATE R 200
R 490 2 Teas and 1 Lunch R 490 2 Teas and 1 Lunch R 490 2 Teas and 1 Lunch
ACCOMPANYING PERSON R 200
TOTAL SECTION D R
*No day delegates allowed. TOTAL SECTION C R
Section e: DIETARY REQUIREMENTS
Food served at the venue is Halaal certified. Please indicate your Kosher requirements.
Special dietary requirements, to register at least 10 days prior to 31 October. (cut off date 22/10/2012)
THURS 1 NOV FRI 2 NOV SAT 3 NOV total
Delegate R 360 2 Teas and 1 Lunch R 360 2 Teas and 1 Lunch R 360 2 Teas and 1 Lunch
Accompanying person R 360 2 Teas and 1 Lunch R 360 2 Teas and 1 Lunch R 360 2 Teas and 1 Lunch
*A surcharge on these food items of R360 per serving (2 teas and 1 lunch) will be for the delegate’s account. TOTAL SECTION E R
Section F
R SECTION B + R SECTION C + R SECTION D + R SECTION E = R
Accommodation and travel arrangements
NOTE: The appointed travel and destination company to the SADA Congress is Events Dynamics. Payment for any bookings via them must be made to them directly.
Please contact: Unathi Mvana
Tel: +27 (0)11 676 3000 (Switchboard), +27 (0)11 676 3452 (Direct), Fax: + 27 (0)86 210 5904, E-mail: sada2012@eventdynamics.co.za,
Register online at: https://ei.eventdynamics.co.za/ei/sada2012.htm
PAYMENT DETAILS (Tick method of payment)
cheque: Please make direct cheque deposit into the SADA bank account.
We do not accept mailed cheques as payment.
EFT (electronic funds transfer): Please make payment into the SADA account. See account details.
Reference: Please use your name and surname as it appears on registration form as a reference.
CREDIT CARD: Please fill in details below.
Charge my: Visa Master Please note we do not accept payment from American Express and/or Diners Club International.
To the amount of R Card no.
Expiry date D D / M M / Y Y Y Y ID no.
Initials and surname of cardholder Initials Surname
Last 3 digits on back of card Date D D / M M / Y Y Y Y
Terms and Conditions
• Full payment of registration fees are required to confirm registration.
• Delegates are responsible for their own accommodation and travel arrangements.
• Delegates are requested to register BEFORE 29 October 2012.
• You will receive a confirmation e-mail (once full payment has been received) from the organisers within 10
working days. Please follow-up should you not have received such a confirmation.
• No payments by EFT shall be accepted after 29 October 2012. Only Credit Cards will be accepted after this date.
• Day registrants or late registrations shall be accepted if payment is made by credit cards.
• No cheques shall be accepted
• You are personally responsible for full payment of registration fees in the event your institution or department
or company does not pay them.
I have read and agree to all the conditions outlined in this registration form.
Account details
Bank: ABSA
Name: The South African Dental Association
Account no: 100 002 1420
Branch code: 632005
Branch name: Park Station
Swift code: ABSA ZAJJ
Cancellations
• Cancellation will only be considered if written notice is received on/by 8 October 2012 in which case a
cancellation fee of 25% will be levied.
• No refund of fees for cancellation of registration made after 8 October 2012
• If notification is not received and confirmed by this office, you will be liable for the full registration fee.
• Cancellations must be notified in writing to the Conference managers.
Unless you indicate your preference otherwise by ticking in the box alongside, you give
SADA permission to share your contact details for marketing purposes to exhibitors
at the Congress.
NO
INITIALS SURNAME DATE D D / M M / Y Y Y Y
SIGNATURE
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