Registration Form

To register, please complete the following form and attach the proof of payment below:

PLEASE NOTE:
Gertie Pretorius: CPD Academy reserves the right to cancel a workshop in the unlikely event of insufficient interest.

Title: (required)

Name: (required)

Surname: (required)

Title of workshop you are registering for: (required)

Preferred name on certificate: (required)

HPCSA Registration category: (required)

HPCSA Registration number: (required)

Contact Numbers:

Home:

Work:

Cell:

Postal Address: (required)

Email Address: (required)

Would you like to receive information on upcoming workshops?
YesNo

Banking details

All payments must be made to:

Bank: First National Bank
Branch: Randpark Ridge
Branch code: 255955
Account number: 63093360279
Account name: H.G Pretorius Inc.
Reference: CPD Workshop date and surname

Attach proof of payment here: