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Registration

 

    General Details


    Title

    Your Name (required)

    Your Surname (required)

    Your Email (required)

    Mobile Telephone (required)

    Home Telephone

    Address Details


    Home Address

    Postal Address

    Course Details


    Preferred Course

    BLS Course Date First Choice

    BLS Course Date Second Choice

    ACLS Course Date First Choice

    ACLS Course Date Second Choice

    Academic Details


    Professional Registration

    Registration Number

    Hospital

    Academic History

    Institution


    Qualification


    Date


    Payment Details


    Payment Method

    CashEFT

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    Undertaking

    I understand that I will be required to pass the entry examination in order to successfully complete the course. (It is recommended that the Textbook be obtained at least 6 weeks prior to Course participation to allow sufficient time for self-study)