Pharmacy Connect - Social Event Personal Details Question Title * 1. Personal Details Firstname Lastname Personal e-mail address Work e-mail address Cell no (personal) Cell no (work) What city do you live in currently? What province do you live in currently? Question Title * 2. How many children do you want to register (R220 per child)? 1 2 3 4 5 6 7 8 9 10 Question Title * 3. Prepayment is required to confirm your registration for the event. I am able to pay the registration fee of R220 per person by: EFT Credit card Bank deposit Submit to Pharmacy Connect