ICON 2018 Conference

Website sponsored by

Clinigen EQUITY

Online Registration

Please use mixed-case lettering.

Please ensure that you receive a confirmation by e-mail from the organisers within 10 working days.

E-MAIL / FAX proof of payment to info@rkcommunication.co.za / + 27 (0) 86 60 60 555.

Important request to companies sponsoring delegates:
Kindly let us have the delegate’s personal postal address and other contact information.

 

Personal Details
Title
 
Initials
 
Surname
 
First Name
 
Preferred Badge Name
 
Occupation
Specify
HPCSA Number
Company / Institution
VAT Number
Postal Address
 
City
 
Province
 
Country
Postal Code
 
Business Telephone
 
Business Fax
Mobile Number
Email Address
Special Dietary Requirements
Accommodation

You are responsible for your own accommodation arrangements.

Where do you plan to stay?
 
Specify
Travel Arrangements

A shuttle service will be provided. If the times below do not suit your needs, we would like to recommend that you make use of a private shuttle or Uber.

Use Shuttle Service
Number of People Using Shuttle
(x R300)


Shuttle from airport to venue

Flight Number
Date
August
Time
(hh:mm)
Shuttle Time


Shuttle from venue to airport

Flight Number
Date
August
Time
(hh:mm)
Shuttle Time
Attendance
Delegate Type:
 




I will attend entire duration


I will only attend specific days - select days:  

Friday
Saturday
Sunday
Social Functions
Delegate
Accompanying
Guests
Welcoming Function
(Friday, 17 Aug)
(Free)
(x R250)  
Dinner
(Saturday, 18 Aug)
(Free)
(x R350)  
Payment

I am personally responsible for full payment of congress registration fees in the event that my company / organisation does not pay them.

I agree
 
Responsible for Payment
 
Method of Payment
 
Credit Card Details

Please note: Credit card details are entered at your own risk. No other parties will be held liable for any damages suffered. Thank you.

Name of Card Holder
Type of Card
Card Number
Expiry Date
(MM/YYYY)
Last 3 Digits on Reverse of Card