REGISTRATION FORM

REGISTRATION FORM

South African Champagne Chiropractic Congress
September 1-4, 1999

and

Pre-Conference (4 day) Durban Beach Package
August 27 - 31, 1999

[FrontPage Save Results Component]

Name:
Address:
Street:	City:
State:	Zip Code:
Country:
Phone:		Fax:
E-mail:

9 Day Package (includes FICS Symposium at Champagne Sports Resort and 4 day Durban Beach package); Prices are PER PERSON and double adult occupancy per room. Rooms can hold two additional children which will be charged at the children rate.

	Registration Prior to June 30^th	After June 30^th
Adult Doctor (includes Symposium)	X 9000.00 USD	X 1,100.00 USD
Adult Spouse	X 800.00 USD	X 900.00 USD
Children (over 7)	X 700.00 USD	X 700.00 USD
Children (/ & under)	X 550.00 USD	X 550.00 USD

TOTAL 9 Day Package	USD	USD
For credit card add 3%	+ 3%	+ 3%

(Includes Chartered bus tour to Champagne Sports Resort. visit to Phe Zulu arid Tala Valley Game Preserve)

5 Day Package- FIGS Symposium at Champagne Sports Resort (Prices are PER PERSON based on double adult occupancy)

	Registration Prior to June 30^th	After June 30^th
Adult Doctor	X 500.00 USD	X 700.00 USD
Adult Spouse	X 475.00 USD	X 550.00 USD
Children (over 7)	X 450.00 USD	X 450.00 USD
Children (/ & under)	X 300.00 USD	X 300.00 USD

TOTAL 9 Day Package	USD	USD
For credit card add 3%	+ 3%	+ 3%

Chartered Tour Bus transportation to Champagne Sports Resort, Phe Zulu and Tala VaIley Games Preserve is $100.00 US per person.

X100.00 USD

Total 5 Day Package

USD

MAKE CHECKS PAYABLE TO CASA CONGRESS ACCOUNT IN U.S. DOLLARS.

For credit card	VISA	MC	AmEx
Name as appears on card
Acct #	Expiration date		Signature

For security reasons, print this form and send it by FAX

For additional information contact:

David Dyson, DC at or
Richard Rosenkoetter at . or
FICS Web Page: