Personal Email Address:

PERSONAL INFORMATION

Title:

First Name:

Last Name:

Gender:
MaleFemale

ID Number (for South African citizens):

Passport Number (for Non-South Africans):

Profession:

Postal Address:

Postal City:

Postal Province:

Postal Code:

Postal Country:

Medical Registration Board:
HPCSASANCAllied HealthPharmacy CouncilOther

If you selected “Other” above, please specify:

Medical Registration Number:

COMPANY / CLINIC DETAILS

Company / Clinic Name:

Physical Address:

City:

Province:

Postal Code / Zip Code:

Country / Region:

Phone Number – Work:

Cellphone Number:

VAT Number:

Practice Number:

FURTHER APPLICATION INFORMATION: TO BE COMPLETED IN FULL AS PER INSTRUCTIONS GIVEN PER SECTION

Do you have any dietary requirements?:
HalaalNone

Qualifications; in detail, including year of completion and institution for each qualification (all are applicable):

Post Graduate Experience; in detail, including work and study and institution for each including dates (all are applicable):

Short Motivation for Attendance (including why you want to attend the Course and how you would use this qualification in your practice) *Motivations will be checked for AI assistance*:

Overseeing Doctor? (This is applicable to all Nurses, Allied Health and Pharmacy Council – NO EXCEPTIONS):
YesNot Applicable (only for Doctors)

Name of Overseeing Doctor:

Year Overseeing Doctor completed the Travel Medicine Course:
Select YearNot Applicable20002001200220032004200520062007200820092010201120122013201420152016201720182019202120222023202420252026

Upload your file: ID document (South African citizens) or Passport document (non-South African citizens) THIS IS A COMPULSORY FIELD