Sexually Transmitted Infections (STI) Online Course - Registration Form

Sexually Transmitted Infections (STI) Online Course – Registration form

Southern African HIV Clinicians Society

Sexually Transmitted Infections (STI) Online Course - Registration Form

Applicant Personal Information:

Title

First Name/s

(As it appears on ID or passport)

Surname

(As it appears on ID or passport)

ID/Passport Number

Country of issue

Billing Address to reflect on the invoice

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Cell Phone Number

Office / Work Phone Number

Email Address

Age

Home Language

Qualifications

Highest Degree/ Qualification

(e.g. MBBcH)

Year Obtained

Other Degree/ Qualification

Other Degree/ Qualification

Year Obtained

Year Obtained

Professional council name

Professional council number

Employment Details

Name of employing institution / organisation

Current job title

Country where you work

Country Other

Province where you work

Province Other

If other, please specify

What is your key purpose/motivation for undertaking this course?

Key purpose/motivation Other

Have you completed any SAHCS courses in the past?

Courses

Courses

Health Care Setting listing

Health Care Other

Service Context (select most applicable)

Service context - subset (select all that apply)

Are you a SAHCS member?

Yes

Unsure

Please state membership number

STI course registration fee - please select your preferred payment method

I agree to pay the course registration fee by bank transfer (EFT) upon receipt of a proforma invoice from SAHCS

I agree to pay the course registration fee via the online payment platform (Payfast)

For online payments via Payfast follow this link https://payf.st/lezg6