Blank Form (#3)DELEGATE Name and Surname:(Conference Attendance Certificate & Badge)Have you previously been a member of SADPAS ? YES NOCategory: (Please select) Clinic Owner Practice Manager Medical Receptionist Medical Technologist Registered Nurse Medical Technologist Qualified Skincare Therapist Financial Administrator OtherOtherDelegate Details:Name of Practice / Clinic / Hospital, Institution, Dr., etc. Delegate Work Tel. No.City in South Africa Delegate Cellphone NoDelegate Email AddressRegional Province - Select -Eastern CapeFree StateGautengKwaZulu-NatalNorthern CapeWestern CapeDo you work with a dermatologist, who can verify you? NO YES Dermatologist (verification doctor) Details:Dermatologist Cellphone No.Dermatologist Work Tel. No.City in South Africa Name of Practice / Clinic / Hospital, Institution, Dr., etc.Dermatologist Email AddressRegional Province - Select -Eastern CapeFree StateGautengKwaZulu-NatalNorthern CapeWestern CapeReceipt Details: SADPAS is not a VAT vendor. SADPAS is a subgroup of The Dermatology Society of South Africa (DSSA), an association incorporated under section 21 of The Companies Act.Name of Practice / Clinic / Hospital, Institution, Dr., etc.EmailFull Postal AddressRegional Province - Select -Eastern CapeFree StateGautengKwaZulu-NatalNorthern CapeWestern CapeCity in South Africa Postal CodeDietary Requirements Do you have any special dietary requirements? None Vegetarian Kosher Halaal OtherOtherWill you attend SADPAS Conference | Social Evening immediately after the Conference? YES NOPayment Method: PAYFAST - please note, bank statement will read Payfast*SADPAS Please use the same email address for PayFast payment as you provided under 'Receipt Details'.Submit Form
