2013 Continuing Professional Development (CPD) Booking Form: EVENT NAME: REGIONAL COMMITTEE KWAZULU NATAL: Managing stakeholder

relationships in South Africa EVENT DATE: 16 April 2013 CPD POINTS: 3 - Three (Networking CPD programme)

Mr/Mrs/Ms/Miss Initials: _______ First names: _______________________ Surname: _____________________ I D No: _________________________________ Male

Female

Home language: ________________

Designation: _______________________________ Invoice to Company or self: ________________________ Company: __________________________________________ Company VAT No: ____________________

The company's/personal postal address (for invoice purposes): _________________________________________ _____________________________________________________________________ Home: __________________________ Postal code: __________

Cell _______________________________

Work (___)______________ Fax (___)______________ Work Switchboard (____)________________ E-mail: __________________________________ Dietary Requirements: _____________________________ Do you have a disability status? If so please specify: _______________________________ Registered with PRISA: Yes

No

Yes

PRISA Registration Number: _______________

I would like to become a member of PRISA:

No

CANCELLATION CLAUSE (Cancellation must be in writing, no telephonic cancellations will be accepted): A cancellation fee of R40.00 (incl. VAT) will be charged if cancelled seven (7) working days prior to the event. The full fee is payable if cancelled five (5) working days prior to the event. Please ensure that you receive an email confirming that your cancellation has been accepted. Delegates booking and not attending the workshop will be liable for the full fee. Substitute delegates are welcome and names must be advised on a company letterhead. Non-registered practitioners substituting for PRISA-registered practitioners will be charged the non-registered practitioner fee. Compulsory: Signature: .. Date: .
I am personally responsible for full payment of these fees in the event that the organisation I represent does not pay them. I have read and understand the cancellation clause.

Company authorised signature: . Date: . Who warrants that s/he is duly authorised hereto. Please ensure that all internal procedures have been followed and finalised. PRISA does not accept responsibility for in-house processes not adhered to, inclusive of Vendor applications.
PRISA BANKING DETAILS: NEDBANK JORISSON STREET BRAAMFONTEIN ACCOUNT NO: 1965206298 BRANCH CODE: 195005 PLEASE FORWARD A COPY OF THE EFT/DIRECT DEPOSIT OR CHEQUE PAYMENT TO US. Attention: Ivonne Blom Fax: 011 326 1259 Tel: 011 326 1262 Email: cpd@prisa.co.za

Confirmation: You will receive confirmation of your booking and invoice by email. Student and member fee rate/s only applicable if PRISA membership fees are paid in full at time of booking. Inappropriate and unethical conduct will be reported to your company.