Treatment Optimisation Online Course - SAHIV Society Conference 2018

Treatment Optimisation Online Course – Registration form

Applicant Personal Information

Title

First Name/s

(As it appears on ID or pass port)

Surname

(As it appears on ID or pass port)

ID/Passport Number

Country of issue

Physical Home Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Postal Address

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

HPCSA number

Practice 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

What courses / topics would like SAHCS to offer in the future?

I agree to the following

Receiving information mailers from SAHCS

(Please tick if you agree)