<p> IISA INSURANCE FORUM LIABILITY - THE REALITY Wednesday, 19 August 2015 from 08h00 to 12h30 Villa Arcadia, Music Room, Hollard, 22 Oxford Road, Parktown single delegate registration section 1 personal details</p><p>Surname: Initials: Title (Mr/Dr/Mrs):</p><p>First Names:</p><p>*ID No: IISA Pin:</p><p>Employer:</p><p>Postal Address:</p><p>Company Vat no:</p><p>Mobile No: E-mail:</p><p>* For IISA Continuous Professional Development hours allocation purposes section 2 Payment Details & Declaration</p><p>Mark registration type and optional extras with X: Ex. Vat Incl. Vat  IISA Corporate Members R263.16 R300.00  Non Member R438.60 R500.00  Paid up IISA Professional Members Complimentary  Retired IISA Member Complimentary Refreshments will be served All meals are Halaal friendly</p><p>Direct Deposit. NB: Invoice and IISA banking details will be sent upon receipt of registration form ** Payment due on presentation of invoice**. Invoice PIN to be used as deposit reference. Please debit my credit card: Visa Master Amex</p><p>Credit Card number:</p><p>Name on Card:</p><p>CVC Code (Last 3 number on reverse side of Expiry Date: (mmyy) card): Payment Option: Straight Budget: ….…. Months DECLARATION: I understand that submitting this form constitutes a registration for the above event. I acknowledge that the Insurance Institute of South Africa does not refund or substitute any fees paid for events and that I will remain liable for payment if I do not cancel the registration before 13 August 2015 or if I fail to attend the event without having cancelled the registration within the stipulated period.</p><p>USE OF YOUR PERSONAL CONTACT INFORMATION</p><p>Your consent is requested to use your personal contact information (email address, and name and company) to receive News@IISA and other industry information. YES / N0</p><p>Signature: Date: …….… / ….…… / 2015</p><p>R.S.V.P. by 13 August 2015 Please note that venue capacity is limited and seats will be allocated upon receipt of completed registration form only on a first come first served basis.</p><p>Please send completed form to: Fax: 0861 01 4472 | E-mail: [email protected]</p>