UCT FHS Registration: Ultrasound Guided Vascular Access

REGISTRATION FORM
Course Name*
Course Date*

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)
ID Number / Passport Number*
Please upload a copy of your ID*

Cancelof
Date of Birth*
DD/MM/YYYY
Nationality*
Highest Qualification*
HPCSA Registration Number
If applicable
Occupation*
Company / Employer*

Contact Details
Email (NB: Your certificate of attendance will be emailed to this address)*
example@example.com
Cell Phone Number*
Postal Address
Postal Code
Country

Other Information
Do you have any special dietary requirements? (NB: Only religious and allergies can be catered for)
For allergies, please provide details:
Do you have any other special requirements that we should be made aware of?

YesNo
If yes, please provide details:
May we add your name to our mailing list to receive notification of future courses?

YesNo

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

My employer/company is paying - please complete the section below "Invoices"I am paying for myself - please make payment of the course fee using the UCT PayU link below.
Individual Payments - UCT PayU
UCT PayU (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 course fee will be auto-populated based on the course selection.

Click proceed and 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.

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).

NB: Cancellations received withing two weeks of the course start date or once you have been given access to the e-learning site are not eligible for a refund.

*Please remember to return to this form and submit your registration once payment has been made.
Company Invoices

For a company to receive an invoice, the following details must be completed.
NB: Tax invoices are only issued to companies. The correct reference must be used as indicated. Please ensure you complete this information as it should appear on the invoice. You should receive an invoice within 15 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.
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 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 upon registration. This ensures your place is reserved and to allow for the pre-course e-learning to be sent to you timeously.

4. We must be informed of cancellations in writing at least three weeks before the start of the course or the full fee will be charged.

5. 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.

6. Certificates will be issued in the name supplied on the application form. Certificates 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.

7. 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.

8. 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*
DD/MM/YYYY
Should be Empty:

REGISTRATION FORM

Personal Details

The following information is required for UCT reporting purposes only:

Contact Details

Other Information

Payment Information

Individual Payments - UCT PayU

Company Invoices

Terms & Conditions