GIO - CPD Reg 2012

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GIO - CPD Reg 2012

GRADUATE INSTITUTE of OPTOMETRY| Postgraduate Education for Optometrists

Click on Programme details for more information and to register for CAS and Monthly CPD Newsletters

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Complete the form below and click on the submit button to complete your registration

REGISTRATION FORM FOR CPD – 2012
10 online Newsletters = 3 CPD points each = 30 CPD points

REGISTRATION DATE 15 February 2012

PLEASE COMPLETE THE FOLLOWING REQUESTED INFORMATION AND FAX OR EMAIL IT TOGETHER WITH CONFIRMATION OF PAYMENT TO THE GRADUATE INSTITUTE OF OPTOMETRY

PLEASE TYPE IN CAPITAL LETTERS

_Surname:

First Names:

Date of Birth:

Sex:

Country of Citizenship:

HPCSA Registration Number:

Identification Number (If not a South African citizen please give PASSPORT identification number)

Contact Mailing Address:

Street Address/Box Number:

City:

Province:

Code:

Country:

Phone number:

Fax Number:

Cell Phone:

Email Address:

Enter name to appear on CPD Certificate:

COST: R 680.00 incl VAT for all electronic newsletters, certificates and submissions to the HPCSA on your behalf
Direct Deposits: (Cash or cheque Only)	ABSA Bank Account. Holder: Investec Private Bank - The Graduate Institute of Optometry Account Number: 01043960306 Reference number: 10010646107 Branch Code: 632005
Internet Banking:	Investec Private Bank Account Holder: - The Graduate Institute of Optometry Account number: 10010646107 Branch Code: 580105
Confirmation of payments must be faxed to 043 7484901 with your name clearly reflected.

Signature

Date

What is 4 +4?

Stef Kriel Dip. Optom. M.HPE CAS