Registration
CIAA 2001
|
|||
Full name: | |||
Affiliation: | |||
Address: | |||
City: | State/Province: | ||
Postal Code: | Country: | ||
Phone: | Fax: | ||
E-mail Address: | |||
Number of Extra Dinner Tickets (ZAR 200 per ticket): | |||
Signature:
|
|||
Amount Payable: |
|||
Conference Fee: TOTAL AMOUNT DUE: R_______________ |
|||
For payment by credit card: |
|||
VISA # | Expiry date: | ||
MC # | Expiry date: | ||
For payment by bank transfer: |
|||
|
|||
Fax together with credit
card information OR bank-transfer receipt to: |