To register on-line, complete this form and click the 'submit' button at the bottom of the page. Please register by no later than 25th August 2011

This form is for use by delegates, dentists and dental auxiliary personnel.

Dental Traders: Click here for the Dental Traders Registration form.

Personal details

Type the required information in the space provided below:

Registration Fees

Fee per Dentist (NDA Members):N$ 3000-00

Fee per auxiliary dental staff member (assistants, hygienists, receptionists, practice managers, etc., including Government employees): N$ 1 500-00

Additional fee per Dentist non-NDA Member:N$ 1000-00

Additional fee per Dental Hygienist non-NDA Member: N$ 1000-00

Additional fee for late registration N$ 1000-00

Calculate your registration fees and enter after each respective column in the block below. Also enter the total registration fees due.

Total Payment Due

Summarise your total payment due in this table. Please see the payment details below.

All payments to be done, either by electronic fund transfer or by direct deposit, to the following cheque account:

Account name: Namibian Dental Association

Bank name: Bank Windhoek, Maerua Mall Branch

Branch code: 483 872

Account number: 8000 664 742

Fax proof of payment for attention: Birgit at +264 61 235 227 or e-mail to dmsup@mweb.com.na

Please note: For security reasons and due to the long delays experienced the NDA does not accept payments by post office mail.

Cancellation/Substitution Policy: Cancellations received 20 or more working days before the congress will be refunded, less a 30% administration fee. No refunds will be made for cancellations received less than 20 working days before the congress or for non-attendance of the congress. Only written notice of cancellations will be considered. Substitutions of delegates can be made at any time.

Accommodation: All delegates are responsible for making their own accommodation arrangements and settling the bill. Please see the Congress Pages for more information.

NOTE THAT ALL BAR FACILITIES AT THE CONGRESS VENUE OR ANY OF THE FUNCTIONS ARE STRICTLY CASH BAR ONLY!!

2011 NDA Congress & AGM - Delegates On-line Registration form

CHOOSE OPTION

Dinner on thursday evening  (This will be for your own

account but please state whether you will attend):

Dinner on Friday evening

(N$ 300-00 Per spouse attending):

To register on-line, complete this form and click the 'submit' button below.

PLEASE COMPLETE Title: Surname & First name: Auxiliary dental staff (assistants, hygienists, receptionists, practice managers, etc) 1st person's surname & first name: 2nd person's surname & first name: Postal address: Town: Country: e-mail address: Telephone & dialing code: Fax & dialing code: Cell:

PLEASE COMPLETE Dentist - NDA Members @ N$ 3000-00  Dental Hygienist or Dental  Assistant @ N$ 1 500-00 Additional fee per Dentist non-NDA Member @ N$ 1 000-00 Additional fee per Hygienist non-NDA Member @ N$ 1 000-00 Additional late registration fee N$ 1 000-00 TOTAL REGISTRATION FEES: N$

PLEASE COMPLETE First name and surname of spouse:

YesNo

YesNo

EVENING FUNCTIONS Please note: The first evening is on everyone’s own account. Spouses are welcome to attend the evening functions. The Hawaiian evening function is at an additional amount of N$300.00.  However, prior notification is necessary, as seats are limited. The Hawaiian evening function is a dress-up party.

PLEASE COMPLETE TOTAL REGISTRATION FEES: TOTAL EVENING FUNCTIONS: GRAND TOTAL DUE: