Class of 1972 Reunion - 30 November - 2 December 2012 REGISTRATION FORM Please complete this form and return it with your payment, by 15 OCTOBER 2012. Your details name: address: Email and mobile number: Your payment South African Rands please. Forward a copy of your deposit slip by Fax or Email attachment to the contact below. 1. cheque (payable to “UCT”) 2. direct (EFT) deposits Bank: Standard Bank of South Africa, Rondebosch Account name: UCT Sundries Account Branch Code: 02 50 09 Account Number: 07 150 3854 Type of Account: Current Reference: 1972surname120098 eg 1972adams120098 3. internet banking Same as direct deposits swift code SBZAZAJJ (foreign payments) Email notification 4. credit card Authority for payment by CREDIT CARD to the University of Cape Town Please debit my American Express MasterCard Visa Other: specify Amount: Card number Last three digits on back: Expiry date: dd mm yy date: Today’s Signature (essential): …………………………… Our contact Please complete this form and return it with your payment, by 15 OCTOBER 2012. Post: Joan Tuff, Alumni Officer, Faculty of Health Sciences, Private Bag X3, Observatory 7935, SOUTH AFRICA. Fax: +27 (0)86 612 6390 or +27 (0)21 447 8955 (mark for attention: Joan Tuff) Email: joan.tuff@uct.ac.za Programme Fri, 30 Nov 12h30 Registration MAC Club, Medical School – 13h00 Lunch 15h00 Tour of the Heart of Cape Town (Transplant) Museum 18h00 Cocktail party Wolfson Pavilion Foyer, Institute of Infectious Disease (IIDMM) –
Class of 1972 Reunion - 30 November - 2 December 2012 REGISTRATION FORM Please complete this form and return it with your payment, by 15 OCTOBER 2012. Your details name: address: Email and mobile number: Your payment South African Rands please. Forward a copy of your deposit slip by Fax or Email attachment to the contact below. 1. cheque (payable to “UCT”) 2. direct (EFT) deposits Bank: Standard Bank of South Africa, Rondebosch Account name: UCT Sundries Account Branch Code: 02 50 09 Account Number: 07 150 3854 Type of Account: Current Reference: 1972surname120098 eg 1972adams120098 3. internet banking Same as direct deposits swift code SBZAZAJJ (foreign payments) Email notification 4. credit card Authority for payment by CREDIT CARD to the University of Cape Town Please debit my American Express MasterCard Visa Other: specify Amount: Card number Last three digits on back: Expiry date: dd mm yy Today’s date: Signature (essential): …………………………… Our contact Please complete this form and return it with your payment, by 15 OCTOBER 2012. Post: Joan Tuff, Alumni Officer, Faculty of Health Sciences, Private Bag X3, Observatory 7935, SOUTH AFRICA. Fax: +27 (0)86 612 6390 or +27 (0)21 447 8955 (mark for attention: Joan Tuff) Email: joan.tuff@uct.ac.za Programme Fri, 30 Nov 12h30 Registration – MAC Club, Medical School 13h00 Lunch 15h00 Tour of the Heart of Cape Town (Transplant) Museum 18h00 Cocktail party – Wolfson Pavilion Foyer, Institute of Infectious Disease (IIDMM)
1972_Registration_form.docx