Your address (our preferred mode!): Cell: Tel: Fax:

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1 AMESA CONGESS 2017 EGISTATION FOM Please rather download the electronic registration form at Then you can type in Word and it to us and we can copy and paste to minimise errors CONTACT DETAILS (please print) Title: First Name: Surname: Postal Address: Postal Code: Institution: Province: Your address (our preferred mode!): Cell: Tel: Fax: Are you a current paid-up AMESA member? Yes No If Yes, please provide your membership number for us to check: If No, please complete the membership form and include the membership fee here: EGISTATION FEE Early egistration: 1000,00 (by 30 April) Normal egistration: 1250,00 (1 May to 31 May) Late egistration: 1 400,00 (after 31 May) Day Visitors@ 400,00/person/ day Mon Tues Wed Thurs Fri Congress materials for day visitors can be pre-ordered only until 10 June at 360 HOSTEL ACCOMMODATION (please mark with an X) Date of arrival: Date of Departure 2 July (5 Nights) 3 July (4 nights) 4 July (3 Nights) 5 July (2 Nights) 6 July (1 Night) 1750, , ,00 700,00 350,00 EVENING FUNCTIONS Tuesday 4 July 2017 Cultural evening (200,00) Thursday 6 July 2017 : Gala dinner (370,00) EXCUSIONS: 5 July 2017 (choose only one and mark with an X) Baywest Mall 100,00 Addo 280,00 Tour of Port Elizabeth 250,00 DIETAY EQUIEMENTS (please mark with an X) TOTAL AMOUNT OWING: None Vegetarian Halaal Diabetic Other- Please specify 14

2 PAYMENT FOM Please complete your egistration Form (page 14), your Payment Form (page 15) and, where necessary, your Membership Application/enewal Form (page 16) and send them with proof of payment to the AMESA Congress Secretariat: by to: (Preferred! emember to attach all the forms) by fax to: by post to: (Only if you must!) The Congress Secretary Nombulelo Mandindi AMESA P.O. Box WITS PAYMENT METHOD (please tick one) Internet payment or bank transfer: Banking details of Congress 2017 Account Name: AMESA Name of Bank: ABSA Branch Code: Branch Name: Wynberg Account Number: Type of Account: Cheque Account Clearly enter your name and/or membership number in the reference section The onus is on you to ensure that we receive the relevant information Cheque or postal order made out to AMESA Credit card: Please debit my credit card account (Visa and MasterCard only) with Card number: CVV Number: (last three numbers on the back of your credit card) Tick your method of payment: Straight: Budget: 6 months 12 months Name on card: Expiry date: Signature: Date: Note: Your registration is not complete until we receive your full payment, and your AMESA membership is paid 15

3 AMESA MEMBESHIP APPLICATION/ENEWAL FOM If you are not a current paid-up AMESA member, you need to complete this section. Please complete in full and in capital letters 1. Membership no (if renewal): 2. Province: Branch: (if known) 3. Membership type: Individual Institutional Associate (e.g. full-time student) 4. Field of interest: Primary Secondary Tertiary 5. For Individual and Associate members only: Surname: First name: Title: Postal address: Postal code: Tel. no: Fax: Name of institution: 6. For Institutional members only: Designation of person to whom correspondence should be addressed (e.g. The HOD Mathematics / Librarian): Name of institution: Postal address: Postal code: Tel. no: Fax: 7. For student (associate) members only: I hereby declare that I am a full-time, pre-service student at the following tertiary institution: Signature: Please include proof of registration at tertiary institution with your application. 8. Membership subscription fee: Mark one, and then include the amount in the membership section and total South Africa, Individual: 140 South Africa, Institutional: 400 South Africa, Associate (Full-time pre-service student at a tertiary institution): 45 South Africa, Life membership: 3500 Other African countries, Individual: 190 Non-African countries, Individual: USD $75 16

4 Please rather download the electronic application form at Application for financial support: AMESA Congress Note: Closing date is 30 April 2017 I,..., would like to apply for financial support to attend AMESA Congress Surname:... First names:... Postal address: Postal code:... Institution:... Area of interest: (Primary / Secondary / Tertiary)... Tel: (Home)... (Work)... Fax: Complete 1 and 2 below and take note of 3: 1. I am an AMESA member: YES / NO... Membership number: I am able to contribute... of the projected. costs for my attendance. 3. I undertake to write an article/report on AMESA Congress 2015 which may be published in AMESA News. Signature:... Date:... Note: A typed ½ to 1 page motivation, as well as a detailed budget must accompany this application. The application will not be considered without a detailed budget. Preference for funding will be given to paid-up AMESA members who will be participating in the congress programme. 17

5 CAPE ECIFE HOSTEL ACCOMMODATION FOM Booking is limited to one group only of up to 60 persons (No individual booking!) Name of organiser of Group Address Number of males: Cell Number: Number of persons in group: Number of females: TOTAL AMOUNT: Number of persons x 1000,00 = x 1000,00 = Please make payment of this group accommodation booking to our AMESA 2017 Congress account details shown below: Account Name: AMESA Name of Bank: ABSA Branch Code: Branch Name: Wynberg Account Number: Type of Account: Cheque Account Clearly enter your group name and state Cape ecife in the reference section. The onus is on you to ensure that we receive the relevant information. Please this form together with proof of payment to 1. Catherina.steyn@nmmu.ac.za 2. congress2017@amesa.org.za 18

6 MEMOABILIA ODE FOM Name: Cell: Address: Important: Golf shirt must be ordered according to your chest size. The chest size provided below is for a tight fitting golf shirt. Please complete Order Form, indicate using an X to mark appropriate box/item and fill in the price. S M L XL 2XL 3XL 4XL 5XL Amount Golf Shirt 53cm 56,5 cm 60cm 63.5cm 67cm 70.5cm 74cm 77.5cm Fleece Jacket S M L XL 2XL 3XL 4XL 5XL Bomber Jacket S M L XL 2XL 3XL 4XL 5XL 440,00 Cap 82,00 Scarf 85,00 Mug 65,00 Add: 50,00 for cash deposits 50,00 TOTAL For any CASH/CHEQUE DEPOSITS please add Banking Details: BAVOOX 387 First National Bank (FNB) Account # Branch Code: Please this completed Memorabilia order form together with your proof of payment to hightidepromo1@gmail.com or fax to Once payment is received you will receive an or SMS confirming your order with a reference number. Please use this reference number when collecting your memorabilia at the conference. If you do not receive an SMS with your reference number within 4 days, please contact