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FCA 2 REFRESHER COURSE REGISTRATION FORM 2021
REFER TO WEBSITE FOR BANKING DETAILS - EMAIL YOUR PROOF OF PAYMENT TO
jhbanaesthesia@gmail.com
- PLEASE USE YOUR NAME + SURNAME AS THE REFERENCE
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First name
*
Your answer
Surname
*
Your answer
e-mail address
*
Your answer
Mobile Number
*
Your answer
Hospital
*
Your answer
Public or Private
*
Public
Private
Required
Do you want CPD points?
*
Yes
No
MP Number (for CPD delegates only)
Your answer
Will you attend in person or virtually?
*
In person at Draeger Woodmead (R4500)
Virtual attendance on Zoom (R4500)
Will you attend the full course or only certain days?
Full course
Day attendance
Clear selection
Daily attendance rates (choose all that apply, no file included)
Monday - No CPD (R1200)
Monday - With CPD (R1600)
Tuesday - No CPD (R1200)
Tuesday - With CPD (R1600)
Wednesday - No CPD (R1200)
Wednesday - With CPD (R1600)
Thursday - No CPD (R1200)
Thursday - With CPD (R1600)
Friday - No CPD (R1200)
Friday - With CPD (R1600)
FILE ONLY (please note a file is included for the full course, both virtual and in person)
R950 with postage
R850 for collection
Clear selection
Postnet branch for delivery of notes (Street address & area)
Your answer
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