Enrolment Form

ENROLMENT FORM

C-A-O Short Course - The Protection of Personal Information Act (POPI Act)
Select your Course*
COURSE DATE:
04 September 2017 08:30 – 12:30

COURSE FEES:
R3,500 per delegate If paid before 22 August
R4,000 per delegate if paid after 22 August
COURSE DATE:
05 to 06 September 2017 08:30 – 16:00

COURSE FEES:
R5,000 per delegate if paid before 22 August
R6,000 per delegate if paid after 22 August
COURSE DATE:
07 to 08 September 08:30 – 16:00

COURSE FEES:
R5,000 per delegate if paid before 22 August
R6,000 per delegate if paid after 22 August
COURSE DATE:
11 to 12 September 08:30 – 16:00

COURSE FEES:
R5,000 per delegate if paid before 22 August
R6,000 per delegate if paid after 22 August
COURSE DATE:
13 to 14 September 08:30 – 16:00

COURSE FEES:
R5,000 per delegate if paid before 22 August
R6,000 per delegate if paid after 22 August
DELEGATE DETAILS
Substitutions may be made at any time prior to the start of the training course
Name*

First NameLast Name
Position*
Email*
example@example.com
Cell Number*

Area CodePhone Number
Tel. Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc
TO REGISTER ADDITIONAL DELEGATES, PLEASE COMPLETE THE INFORMATION ON THE NEXT PAGE.
COMPANY / ORGANISATION DETAILS
Please supply company details as required for a SARS compliant Tax Invoice
Company Name*
Department / Division*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
VAT Number*
Fax Number*
PAYMENT NB
Use your Invoice Number as reference on your deposit/EFT

Make Payment to Central Applications Office
First National Bank
Acc No: 62142087247
Cheque Account
Branch: 221426
Purchase Order Number*
To be incl. on Invoice if applicable
Do you require separate invoices for each delegate?*

YESNO
Payment Contact Person*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
AUTHORISATION
Name*

First NameLast Name
Position*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Authorising Signature*

Clear
Signature Date*

DayMonthYear
Your booking is confirmed as soon as we receive your completed enrolment form. If you need any assistance whatsoever, please call us on 031 268 4444

Submission of this enrolment form constitutes acceptance of our Terms and Conditions, and also serves as confirmation of your authority to make the booking and ensure payment on behalf of your Organisation.

DELEGATE DETAILS

Delegate 2
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 3
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 4
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 5
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 6
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 7
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 8
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 9
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc

Delegate 10
Name

First NameLast Name
Position
Email
example@example.com
Cell Number

Area CodePhone Number
Dietary Requirements*
Please specify*
Example: allergies, etc
Should be Empty:

DELEGATE DETAILS