REGISTRATION FORM (Clinical Coding)

REGISTRATION FORM

Clinical Coding Courses
Course Name*
Course Date: (please enter distance learning if you are selecting this option)
Personal Details
Title (e.g.: Dr / Mr / Mrs / Miss)
Name

First NamesSurname
Full Name to appear on certificate*
Student Number (if previously registered with UCT)
Nationality*
ID Number / Passport Number*
Date of Birth*

MonthDayYear
Date
Occupation
Highest Qualification
Company / Employer
Gender (This information is required for UCT reporting purposes only)
Race (This information is required for UCT reporting purposes only)
Disability (This information is required for UCT reporting purposes only)

NoYes
If yes, please specify
Postal Address (NB: Your certificate will be posted via registered mail to this address):

Street Address

Street Address Line 2

CityCountry

Postal Code
Cell Phone Number
Email
example@example.com
Miscellaneous
Do you have any other special requirements that we should be made aware of?

YesNo
May we add your name to our mailing list to receive notification of future courses?

YesNo
How did you hear about this course?

Faculty InfomailerCEU Health EmailCEU WebsiteUCT CalenderBizcommunityFacebookTwitterWord of MouthOther
PAYMENT
Who is paying for you to attend this course?*

My employer/company is paying - please complete the following section "Invoices". Payments via EFT can be made using the bank details below.I am paying for myself - please use the PayU portal for payments via Card.
PayU Portal (payment via Card):

1. Direct to the following link: https://payments.uct.ac.za/professional-development/
2. Faculty, select FHS
3. Department, select Continuing Education Unit
4. Course, select your applicable course
5. Schedule, select the applicable date and time
6. Complete your First name
7. Complete your Surname

The amount will be auto-populated based on the course selection

Press proceed and you will be redirected to the terms and conditions page, where you are required to accept the terms and conditions associated with making a payment on the page

You will be redirected to the Payment Gateway, where you will be required to enter your card details.

NB: Please note we accept ZAR’s only and the payment gateway is enabled for Mastercard and Visa. Your issuing bank will require your authorization for the transaction for 3DS secure (you will receive a notification from your bank to enter a OTP on the site to confirm the payment).
Electronic Transfers and Direct Deposits for Individuals and Companies:

Account Name: University of Cape Town Sundries Account

Riverside Centre, Main Road, Rondebosch, 7700, South Africa

Account Number: 071503854

Branch: Rondebosch, 025009

SWIFT Code: SBZAZAJJ

Reference:

- for individuals: 233514 [Your Initial & Surname] e.g. 233514PJones

- for companies: 233514 [Invoice Number] e.g.: 233514123456

Proof of payment must be emailed to ce.administration@uct.ac.za
Company Invoice

Please note: Tax invoices are only issued to companies. Individuals paying privately must use the banking details in Section A below for payment. The correct reference must be used as indicated. Please do not complete Section B if you are paying as an individual. Please ensure you complete this information as it should appear on the invoice. Invoices will be emailed to the contact person indicated below. Please ensure you give the correct person’s details. You should receive an invoice within 10 working days from the date of request. If payment is unlikely to reach us before the start of the course, we require a letter from your company stating their intention to pay the fee on receipt of an invoice. Once payment has been made, proof of payment must be emailed to ce.administration@uct.ac.za. For a company to receive an invoice for its employee/s attending a course, the following information must be completed:
Name of Company
Postal Address
Postal Code
Street Address
Postal Code
VAT registration number
Purchase Order Number
Business Sector (e.g. Commercial, Government, NPO)
Industry Type (e.g. Finance, Electronics, Education)
Contact person (e.g. Finance officer) to whom the invoice should be emailed
Name
Position
Email
example@example.com
Telephone
Terms & Conditions
1. We will acknowledge receipt of your registration form. If there are no available spaces, you will receive notice of this and your name will go on a waiting list.

2. Closing date for registrations is dependent on the particulars of each course. You may not cancel your registration after registrations have closed.

3. Fees are due one week before the start of the course, unless otherwise arranged with the Continuing Education Unit.

4. You will be emailed a course information letter one week before the start of the course.

5. We must be informed of cancellations in writing at least one week before the start of the course or the full fee will be charged.

6. UCT reserves the right to take any legal proceedings to recover the full fees payable, and to recover the costs in connection with such recovery.

7. Certificates will be issued in the name supplied on the application form. Where possible, certificates will be handed out at the final lecture. If not, they will be posted via registered mail to the address on this form. No certificate will be issued until full payment of the course fee has been received.

8. UCT reserves the right to cancel the course if insufficient registrations are received, in which case, the course fee will be refunded in full if already paid.

9. Certificates will not be issued to any student who is not in financial good standing with UCT.

I have read and accept these terms and conditions.
Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

REGISTRATION FORM

Personal Details

Miscellaneous

PAYMENT

Company Invoice

Terms & Conditions