Centre for Diabetes and Endocrinology (Pty) Ltd Reg. No. 1994/001693/07 , Houghton Estate, 2198 Telephone: 011 712-6000 PO Box 2900, Saxonwold, 2132 Fax: 086 247 0674 Name of Cardholder Amount to be deducted Type of Credit Card (Tick box to right of Logo) The CDE 5 Day Advanced Course in Diabetes Care for Health Care Professionals Credit Card Number Please complete the following for manual credit Expiry Date (mm/yyyy) card authorisation and fax to Security Number (Last 3 Digits on back of Card) 086 247 0674 Signature of Cardholder Date dd/mm/yyyy
Centre for Diabetes and Endocrinology (Pty) Ltd Reg. No. 1994/001693/07 , Houghton Estate, 2198 Telephone: 011 712-6000 PO Box 2900, Saxonwold, 2132 Fax: 086 247 0674 The CDE 5 Day Advanced Course in Diabetes Care for Health Care Professionals Please complete the following for manual credit card authorisation and fax to 086 247 0674 Name of Cardholder Amount to be deducted Type of Credit Card (Tick box to right of Logo) Credit Card Number Expiry Date (mm/yyyy) Security Number (Last 3 Digits on back of Card) Signature of Cardholder Date dd/mm/yyyy
5-day-cc-authorisation.docx