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DELEGATE(S) REGISTRATION FORM Kindly complete and return this form to Africa Media Corporation: Address: 132 East 43rd Street, Suite 205, New York, NY 10017, USA Tel: +1-212-470-0960 or E-mail: register@sabusinesssummit.com

PARTICIPATING DELEGATE Title

Prof ___

Dr ___

Mr ___

Mrs ___

Surname …………….……………………………………

Ms ___

Other …………………………………………………………………….

First name ……….…………………..…………..…( name to appear on badge)

Organisation/Company/Institution………………………………………..………………………...…………………….………………………. Department..……………………………...…………………Email(s)….…….……………………….……………………………..…………... Complete Address…………………………………………….…...........…………………………………………………………………….…… City ……………………………………… Postal code/Zip code ……..…………State or Country ………………………..…………..…… Telephone Code (…….…) No ………………………………..………… Fax Code (…….….) No...…………...…………..….………….

TYPE OF EVENT Event

Date

Conference

February 28, 2014 08:00-15:00

Will you attend?

Awards Banquet

February 28, 2014 18h00 to 23:00pm

Will you bring a guest/s?

ACCOMMODATION - PLEASE BOOK DIRECTLY WITH HOTELS IN THE SANDTON BUSINESS DISTRICT. SPECIAL RATE FOR SABSA DELEGATES: SABSA has secured a limited discount at Radisson Blu, the event venue. To see how you can benefit from these special discounts, please contact the hotel directly at +27 (11) 245 8000 or email them at info.johannesburg@radissonblu.com (Latest by February 7, 2014). Kindly quote SABSA when booking for discounted rates.

PAYMENTS DESCRIPTION

TOTAL (in dollars or rand)

Registering for Summit Banquet Dinner Only

$ $

R R

Group Registration (Number of delegates)

$

R

Total payments with this form

$

R

Bank Account Details: Beneficiary: Africa Media Corp. Name of Bank: Bank of America Account No.: 483030587453 Swift Code: BOFAUS3N (Dollar only) Swift Code: BOFAUS6S (Rand only)

METHOD OF PAYMENT ____ Credit Card

____Wire Transfer

____Check (make checks payable to the Africa Media Corp.

Please mail checks to Africa Media Corp in New York—132 East 43rd Street, Suite 205, New York, NY 10017, USA)

Credit Card Payment Details ____American Express

____MasterCard

____Visa

____Discover

____Diners Club

Credit Card Number ________________________________________________ Expiration date________________ 3-digit security code__________ Signature_________________________ Amount___________________________ CANCELLATION POLICY: Registered places must be cancelled in writing. Cancellations made within thirty-one days of the commencement date will be subject to a 50% retention fee, thereafter no refunds will be considered. You can pay either in US dollars or South African rand. Please quote name of delegate or Invoice Number when payment is made. Please Email proof of payment to register@sabusinesssummit.com for attention SABSA 2014. Admittance to both the Conference & Awards ceremony will be restricted to delegates who have paid in full. The organisers reserve the right to refuse admission where evidence of payment cannot be shown.

…………………………………………………….

SIGNATURE

South African Business Summit & Awards 2014

…………………………………………..

DATE

Registration Form


2014 Registration Form