Print this form, complete and fax for attention: Birgit Gärtner,

fax no: +264 61 235 227, by no later than 25th August 2011.

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

Dental Traders should use the Traders Registration Form

Personal details

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 (Please add dialing code):

Fax (Please add dialing code):

Cell:

Registration Fees

Registration fees includes all tea breaks, lunches and the Friday night Hawiian  evening function at the Tiger Reef Beach Bar .

Fees are all inclusive, are for the duration of the congress and no credit or discount will be allowed for lunches or evening functions not attended.

Spouses pay no registration fees, but will have to pay for evening functions.

Fee per Dentist (NDA Members)

Fee per auxiliary dental staff member (assistants, hygienists, receptionists, practice managers, etc., including Government employees):

Additional fee per Dentist non-NDA Member:

Additional fee per Dental Hygienist non-NDA Member:

Additional fee for late registration (after 25th August 2011):

TOTAL REGISTRATION FEES:

FEE N$

3000.00

1500.00

1000.00

1000.00

1000.00

Quantity

TOTAL

________

Evening Functions

EVENING FUNCTIONS

Please note:

The first evening is on everyone’s own account

The Hawaiian evening function is at an additional amount of N$300.00. 

The Hawaiian evening function is a dress-up party.

First name and surname of spouse:

___________________________________________

Thursday, 15th September Dinner (This will be for your own account but please state how many people will attend):

Hawaiian evening, Friday evening 16th September 2011 (Per spouse attending):

TOTAL EVENING FUNCTIONS:

FEE N$

300.00

Quantity

TOTAL

________

Total Payment Due

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

TOTAL REGISTRATION FEES:

TOTAL EVENING FUNCTIONS:

GRAND TOTAL DUE:

TOTAL N$

________________

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 Print & Fax Registration form