Name *

First

Last

Checkboxes

• Mr
• Mrs
• Ms
• Dr
• Prof

Gender

• Male
• Female

Profession

Institute/Organization

Position

Sponsorship status

• Individual
• Organization

Contact details

Telephone/mobile

Email *

Special dietary requirements

• Yes
• No

If yes, please specify

Invoicing detail. Name of person and/ or Organisation to whom the invoiceshould be adressed

Did you apply for scholarship

• Yes
• No

Motivational letter submitted

• Yes
• No

Course expectations

Banking Details: FCA account details: Stanbic Bank: Account name: College of Health Sciences UZ: Account number 914 000 1014 306, Branch: Parklane. ZWL account details: Stanbic Bank Parklane Branch, Acc number 914 0000 6695 62 Ref: Health Research Ethics Course: March 2020 For further information, or to secure your booking please contact: Tel: +242 708020 Email: rsc sacoreoffice@gmail.com cc pure.chandiwana@gmail.com or +263 775 495 566

Name

Submit