UCT FHS Registration: Adv HIV & Adherence Counselling

REGISTRATION FORM

UCT FHS Short Courses & Workshops
Please note that if you have been academically excluded from UCT, or not in financial goodstanding with UCT, you will not be allowed to register for this short course.
Course Name*
Course Date*

Personal Details
Title (e.g.: Dr / Mr / Mrs / Miss)
Name*

First NamesSurname
Student Number (if previously registered with UCT)
ID Number / Passport Number*
Please upload a copy of your ID*

Your name as it appears on your ID will be printed to the certificate.
Cancelof
Date of Birth*
DD/MM/YYYY
Nationality*
Highest Qualification*
HPCSA / SANC Number
If applicable
Occupation*
Company / Employer*

Contact Information
Email (your digital certificate will be emailed to this address)*
example@example.com
Cell Phone Number
Address
Postal Code
Country

Other Information
Do you have any special dietary requirements? (only religious or allergies can be catered for): (NB: This section does not need to completed for online courses)

KosherVegetarianHalaalNoneAllergies
For allergies, please provide more information here
Do you have any other special requirements that we should be made aware of?

YesNo
If yes, please provide more information here

Payment Information
Who is paying for you to attend this course?*

My employer/company is paying - please complete the following section "Company Invoice"I am paying for myself - please using UCT PayU information below for direct payment by card
UCT 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 and surname

The course fee will be auto-populated based on the course selection.

Once you have clicked proceed, you will be directed 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 then be directed to the Payment Gateway, where you will 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 an OTP on the site to confirm the payment).
Company Invoice
Please do not complete this section if you are paying as an individual.

Tax invoices are only issued to companies.

Invoices will be emailed to the contact person indicated on this section. 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 upon receipt of the 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 (to whom the invoice must be issued)
Postal Address
Postal Code
Street Address
Postal Code
VAT registration number
Purchase Order Number (if applicable)
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 be notified.

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 two weeks before the start of the course, unless otherwise arranged with the Continuing Education Unit.

4. We must be informed of cancellations in writing at least two weeks 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 digital format only and emailed to the email address provided on this form. No certificate will be issued until full payment of the course fee has been received.

8. Certificates will not be issued to any student who is not in financial good standing with UCT, or who has been academically excluded from UCT, or any other univeristy.

9. 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.

I have read and accept these terms and conditions.
Signature*

Clear
Date*
DD/MM/YYYY
Should be Empty:

REGISTRATION FORM

Personal Details

The following information is required for reporting purposes only.

Contact Information

Other Information

Payment Information

Company Invoice

Terms & Conditions