T-Host IT Developer Event Application for CPD Recognition of Activities Section A : Company information Company Name Trading Name Type of Business Select Business Type Employer Accredited Provider University Industry Association Other Other (please specify Physical Address Code Postal Address Code VAT Number Website Contact Person Title Select Title Dr Hon Mr Mrs Ms Miss Prof Rev Initials Name & Surname Tel (work) Facsimile E-mail Would you like to receive information regarding IISA market activities and educational matters? Please Select Yes No next Section B : Activity Details Programme/Activity Title Is it a Financial Services industry specific/relevant programme? Date of event Event Duration Please indicate which FAIS product categories this CPD activity will be applicable: 1.2 Short Term Insurance Personal Lines 1.6 Short Term Commercial Lines General Business Skills Are you able to provide an auditable attendance register for the event? Please Select Yes No May we publish this event on the IISA CPD Calendar? Please Select Yes No May we publish this event on the IISA Online CPD System? Please Select Yes No Is the activity formally assessed or examined? Please Select Yes No Add another Programme/Activity? Activity 2 Programme/Activity Title Is it a Financial Services industry specific/relevant programme? Date of event Event Duration Please indicate which FAIS product categories this CPD activity will be applicable: 1.2 Short Term Insurance Personal Lines 1.6 Short Term Commercial Lines General Business Skills Are you able to provide an auditable attendance register for the event? Please Select Yes No May we publish this event on the IISA CPD Calendar? Please Select Yes No May we publish this event on the IISA Online CPD System? Please Select Yes No Is the activity formally assessed or examined? Please Select Yes No Add another Programme/Activity? Programme/Activity Title: Is it a Financial Services industry specific/relevant programme? Date of event Event Duration Please indicate which FAIS product categories this CPD activity will be applicable: 1.2 Short Term Insurance Personal Lines 1.6 Short Term Commercial Lines General Business Skills Are you able to provide an auditable attendance register for the event? Please Select Yes No May we publish this event on the IISA CPD Calendar? Please Select Yes No May we publish this event on the IISA Online CPD System? Please Select Yes No Is the activity formally assessed or examined? Please Select Yes No back next Section C : Attachments Activity Agenda Programme outline Academic records Section D : Payment Details Application Fee = R500.00 Admin fee for single once off event = R1 500.00 Admin fee for single event with repeat dates ie ELearning/Roadshows = R2 000.00 Conferences & Courses/Workshop fees will be confirmed once application is reviewed *VAT will be charged on all amounts Payment method Please Select I enclose a cheque/bank draft made payable to Insurance Institute of South Africa I enclose proof of direct deposit Please debit my credit card IMPORTANT: Please use Company Name & CPD Application as deposit reference. First National Bank, Hyde Park Branch Code: 255805 Account Type: Current Account Name: IISA Trading Account No: 6212 2481 641 SWIFT Code: FIRNZAJJ950 (for international payments only) Foreign deposits: Please add ZAR 120.00 per transaction for bank transaction charges. Credit Card Details Card Type Please Select Visa Master Diners Amex Credit Card number Name on Card Expiry Date CVC Code (Last 3 number on reverse side of card) Payment Option Please Select Straight Budget Budget Period Please Select 3 Months 6 Months 12 Months DECLARATION: I understand that the Insurance Institute of South Africa does not refund or substitute any fees paid for services rendered. I understand that it is the responsibility of the event organiser to communicate the fact that this event is registered with IISA for CPD purposes to the attendees and that the information on the attendance register will be shared with IISA for recording purposes. In this regard the IISA may make contact with the attendees concerned where such an individual is not on the IISA system. The purpose of this contact is to request the relevant information from such a person, should they wish the IISA to keep record of their attendance at the event for CPD purposes. back submit Thank you for submitting your application. We will contact you in the near future with an outcome of your application Please turn on javascript to submit your data. Thank you!
