FORM TO BE COMPLETED BY ALL DELEGATES AND GUESTS, SPOUSES, TRAVELING COMPANIONS OR PARTNERS OF ATTENDEES

S A SOCIETY OF NUCLEAR MEDICINE 18 th Biennial Congress (10 to 12 August 2018) CSIR International Convention Centre, Pretoria, Gauteng Province, South Africa NUCLEAR MEDICINE: NewCLEAR MEDICINE BASICS TO CUTTING EDGE FORM TO BE COMPLETED BY ALL DELEGATES AND GUESTS, SPOUSES, TRAVELING COMPANIONS OR PARTNERS OF ATTENDEES NOTE: This form must be completed for each every Delegate Guest/Spouse/Traveling Companion of an Attendee, i.e. (a) (b) all Delegates, Sponsors that will be attending the Conference Sessions ( must therefore pay Registration Fees) will be enjoying Meals, etceteras; as well as all as well as Guests/Spouses/Companions of Attendees, Sponsors who will not be attending the Conference Sessions will therefore not be paying Registration Fees, but will be enjoying Meals, etceteras, where-after it must be returned by email to either Ronell Maree of SASNM [ronell.m@lantic.net] or SASNM s Congress Co-ordinator [amaree1@lantic.net]. Also see the last page hereof re Visa Requirements. For enquiries or assistance, please contact Ronell on +27 (0) 83 279 7593. A. PERSONAL DETAILS 1. DELEGATE, GUEST, SPOUSE, PARTNER AND/OR ATTENDEE: First name (name to appear on badge) Surname Title: Mr Mrs Ms Dr Prof Other HPCSA or similar No Gender: Male Female ID/Passport No Category: Delegate Exhibitor Sponsor Guest/Spouse Other I will be paying for Registration attending Sessions I will NOT be paying for Registration, nor attending Sessions Organization/Company Postal Address Town/City Postal Code/Zip Country Tel code ( ) number Fax code ( ) number E-mail Mobile number 1 of 11

B. REGISTRATION 1. REGISTRATION COSTS: (Fee for Attendees includes Conference Sessions, Delegate Bag, Tea, Coffee, Snacks, Printed Material, as well as the Welcom e Reception the Theme Gala Evenings) NOTE: Upon receipt of your completed Registration Form, a confirmation of your registration, as well as an invoice reference number will be forwarded to you. Once we have received your proof of payment, your registration will be activated. A. "EARLY BIRD" REGISTRATION COSTS: (i.e. Registration Forms received on or prior to 31 March 2018 payments received within 7 days from dispatch of Invoice) CATEGORY: ATTENDING ENTIRE CONGRESS (RATE FOR ALL THREE DAYS) Under Grad ATTENDING ONLY PART OF CONGRESS (RATE PER DAY) Under Grad PAID-UP SASNM MEMBERS CONFERENCE R4 850.00 R2 915.00 R1 210.00 R1 940.00 R1 170.00 R 485.00 NON-SASNM MEMBERS EXHIBIT ORS SPONSORS CONFERENCE R6 050.00 R3 630.00 R1 450.00 R2 420.00 R1 450.00 R 580.00 AT T ENDEES NOT LECT URES, BUT REQUIRING LUNCH T EA R1 890.00 R1 890.00 R1 890.00 R1 030.00 R1 030.00 R1 030.00 AT T ENDEES COCKT AIL AND GALA EVENINGS ONLY R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 2 of 11

B. NORMAL REGISTRATION COSTS: (i.e. Registration Forms received between 1 April 31 May 2018 payments received within 7 days from dispatch of Invoice) CATEGORY: ATTENDING ENTIRE CONGRESS (RATE FOR ALL THREE DAYS) Under Grad ATTENDING ONLY PART OF CONGRESS (ONLY ALLOWED FOR 1 DAY) Under Grad PAID-UP SASNM MEMBERS CONFERENCE R5 820.00 R3 500.00 R1 450.00 R2 330.00 R1 400.00 R 580.00 NON-SASNM MEMBERS EXHIBIT ORS SPONSORS CONFERENCE R7 260.00 R4 360.00 R1 740.00 R2 900.00 R1 740.00 R 700.00 AT T ENDEES NOT LECT URES, BUT REQUIRING LUNCH T EA R1 890.00 R1 890.00 R1 890.00 R1 030.00 R1 030.00 R1 030.00 AT T ENDEES COCKT AIL AND GALA EVENINGS ONLY R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 3 of 11

C. LATE REGISTRATION COSTS: (i.e. Registration Forms received between 1 June 15 July 2018 payments received within 7 days from dispatch of Invoice) CATEGORY: ATTENDING ENTIRE CONGRESS (RATE FOR ALL THREE DAYS) Under Grad ATTENDING ONLY PART OF CONGRESS (ONLY ALLOWED FOR 1 DAY) Under Grad PAID-UP SASNM MEMBERS CONFERENCE R6 985.00 R4 200.00 R1 740.00 R2 800.00 R1 680.00 R 700.00 NON-SASNM MEMBERS EXHIBIT ORS SPONSORS CONFERENCE R8 710.00 R5 230.00 R2 090.00 R3 480.00 R2 090.00 R 840.00 AT T ENDEES NOT LECT URES, BUT REQUIRING LUNCH T EA R1 890.00 R1 890.00 R1 890.00 R1 030.00 R1 030.00 R1 030.00 AT T ENDEES COCKT AIL AND GALA EVENINGS ONLY R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 R 600.00 4 of 11

2. APPLICABLE FEES: (Please tick the appropriate boxes in accordance with the categories fees indicated above.) REGISTRATION TYPE (Please tick) Early Bird Registration Normal Registration Late Registration DELEGATE TYPE Physician, etc Radiographer Student Other Physician, etc Radiographer Student Other Physician, etc Radiographer Student Other DELEGATE CATEGORY Paid-up Members Non-members NOT but requiring lunches teas attending Cocktail Gala evening only Paid-up Members Non-members NOT but requiring lunches teas attending Cocktail Gala evening only Paid-up Members Non-members NOT but requiring lunches teas attending Cocktail Gala evening only R4 850.00 R6 050.00 R2 915.00 R3 630.00 R1 210.00 R1 450.00 R1 890.00 APPLICABLE RATE R 600.00 R5 820.00 R7 260.00 R3 500.00 R4 360.00 R1 450.00 R1 740.00 R1 890.00 R 600.00 R6 985.00 R8 710.00 R4 200.00 R5 230.00 R1 740.00 R2 090.00 R1 890.00 R 600.00 R1 940.00 R2 420.00 R1 170.00 R1 450.00 R 485.00 R 580.00 R1 030.00 R 600.00 R2 330.00 R2 900.00 R1 400.00 R1 740.00 R 580.00 R 700.00 R1 030.00 R 600.00 R2 800.00 R3 480.00 R1 680.00 R2 090.00 R 700.00 R 840.00 R1 030.00 R 600.00 5 of 11

As indicated above, I am planning to attend (1) the entire Congress or (2) only part of the Congress as I have ticked one of the Daily Rates referred to above, kindly note that I will in fact be attending on: Friday, 10-08-2018 Saturday, 11-08-2018 Sunday, 12-08-2018 C. ACCOMMODATION Delegates are welcome to arrange pay for their own accommodation. However, the SASNM Organizing Committee has negotiated a favourable deal with the City Lodge Hotel, Lynnwood who agreed to discount their normal (2017) prices to fix these prices for the SASNM Congress in spite thereof that the Congress will only be held during the middle of 2018. In view of the successful negotiations, SASNM can now offer all Delegates the following accommodation packages: ACCOMMODATION PACKAGES AVAILABLE THROUGH SASNM A. ACCOMMODATION - SINGLE: (ONE PERSON PER ROOM.) B. ACCOMMODATION - SHARING: (TWO PEOPLE PER ROOM) ATTENDING ENTIRE CONGRESS: ALL INCLUSIVE PACKAGE DEAL FOR BED BREAKFAST - 3 NIGHTS (INCLUDING VAT) R4,110.00 PER PERSON FOR THE DURATION OF THE CONGRESS R2,700.00 PER PERSON SHARING (OR R5,400.00 PER ROOM) FOR THE DURATION OF THE CONGRESS ATTENDING ONLY PART OF CONGRESS: ALL INCLUSIVE RATE PER DAY FOR BED BREAKFAST (INCLUDING VAT) R1,370.00 PER PERSON PER NIGHT R900.00 PER PERSON SHARING (OR R1,800.00 PER ROOM) PER NIGHT The above rates are below the said Hotel s normal rates as advertised on the Internet, being R6,230.00 (394 EUR, 355 GBP, 463 USD) per room for the duration of the Congress or R2,076.00 (131 EUR, 118 GBP, 154 USD) per room per night. The afore-mentioned amounts are inclusive for bed breakfast thus, the SASNM 2018 Organizing Committee has decided to name the said City Lodge, Lynnwood as its Preferred Hotel for Delegates to the SASNM 2018 Congress. The Organizing Committee will therefore prefer it if most (if not all) of the delegates attendees could be accommodated at the City Lodge, Lynnwood thus, people are encouraged to team up to share rooms. As indicated in the above-mentioned Cost Structure, there is quite a difference between the single sharing rates it therefore makes financial sense for people to share. The travel time between this Hotel the CSIR Convention Centre is about 10 minutes (depending on traffic conditions). Those Delegates that will be making use of the Shuttle Service SASNM will provide between the Johannesburg (OR Tambo) International or Lanseria Airports the Hotel @ R800.00 per person return, will also be entitled to make use of the daily Shuttle Service that will be provided between the City Lodge, Lynnwood the Convention Centre without any further charge. Delegates that do not wish to make use of the Airport Shuttle Service, but wish to make use of the daily Shuttle Service between the Hotel the Convention Centre will, however, be required to pay R400.00 per person. Please note that the Hotel has limited accommodation available all rooms that are not pre-booked by SASNM by 1 May 2018 will be released into their system for marketing to other clients. It is therefore of the utmost importance that interested parties must inform SASNM as soon as possible what their accommodation shuttle service requirements will be. This can be done by either completing the relevant sections of this form submitting same to ronell.m@lantic.net, or by sending an e-mail to the SASNM 2018 Congress Coordinator (amaree1@lantic.net) who will then arrange for the required booking confirmations invoicing. 6 of 11

In view of the afore-mentioned in order to assist SASNM in this regard, kindly also complete the following (if applicable): 1. ACCOMMODATION REQUIRED: (Please tick the appropriate boxes in accordance with your requirements) SINGLE SHARING ACCOMMODATION TYPE REQUIRED PREFERRED BED TYPE One person per room (One double or two single bed) Two persons per room (Two single beds) One couple per room (Double bed) PACKAGE DEAL FOR ENTIRE CONGRESS Single Sharing APPLICABLE DAILY RATE FOR PART OF CONGRESS Single (one night only) Sharing (one night only) IF APPLICABLE, DETAILS OF OTHER DELEGATE, SPOUSE, PARTNER AND/OR TRAVELING COMPANION(S) WITH WHOM YOU WOULD LIKE TO SHARE A ROOM/ACCOMMODATION FACILITY: Please note: (a) All travelling, registration accommodation costs for an accompanying spouse/partner/travel companion(s) will be for the account of the Delegate. (b) In addition to the information required hereunder, you must also complete a Registration Form in respect of each of your travelling companions. These Forms are available on our Website, www.sasnm.com. I. (title) (first name) (surname) will be sharing a room with (title) (first name ) (surname) being a / my - Category: Speaker Fellow Delegate Sponsor Exhibitor Guest/Spouse/Companion from Organisation/Company Position Postal address: Town/City Postal Code/Zip Tel code ( ) number Fax code ( ) number E-mail Mobile number As SASNM s negotiations were successful, please reserve the required accommodation accompanying meals for me forward an Invoice based on the negotiated rates indicated above, as soon as possible, please. I / We will be checking in on: Thursday, 09-08-2018 Friday, 10-08-2018 Saturday, 11-08-2018 I/We will be checking out on: Friday, 10-08-2018 Saturday, 11-08-2018 Sunday, 12-08-2018 I undertake to arrange, on receipt of a detailed Invoice in this regard, for full payment of the required amount for the above-mentioned (number) nights of accommodation all accompanying meals. 7 of 11

D. DIETARY AND OTHER SPECIAL REQUIREMENTS 1. IF APPLICABLE, PLEASE INDICATE ANY DIETARY AND/OR OTHER SPECIAL REQUIREMENTS: Kosher (Beth din) Halaal Vegetarian Other Special Requirements/Allergies Hearing Impaired Visually Impaired Physical disability (please specify) E. AIRPORT TRANSFER NOTE: The SASNM Organising Committee will arranged for the availability of a Shuttle Service to transport Delegates between Johannesburg International (O R Tambo) Lanseria Airports the Hotel, as well as to the Congress Venue on a daily base. This service will be available at a reduced price of R800 per person, but the airport shuttles will only be available on the day before the last day of the Congress, i.e. on 9 12 August 2018. Arrangements for a shuttle service required on any other day can be facilitated, but as the reduced price is only applicable on the afore-mentioned days, this will only be done on receipt of a s p ecial request the price will then be fixed by special arrangement. 1. ARRIVAL INFORMATION: [NOTE: Availability of the Shuttle Service on any date other than the date mentioned below, can not be guaranteed will only be made available if it is specifically requested then only at a price that will be negotiated with the supplier at that stage.] Arrival at (Johannesburg International (O. R. Tambo) / Lanseria (Airport): Arrival from (City) : on 9 August 2018 Airline : Arrival time : AM / PM Flight No : No of persons : *** Please note: The times, as well as from where at the Airports the various Shuttles will be departing, will be advised in your confirmation letter. 2. DEPARTURE INFORMATION: [NOTE: Availability of the Shuttle Service on any date other than the date mentioned below, can not be guaranteed will only be made available if it is specifically requested then only at a price that will be negotiated with the supplier at that sta ge.] Departure from Johannesburg International (O. R. Tambo) or Lanseria (Airport): Departure to (City): on 12 August 2018 Airline : Departure time : AM / PM Flight No : No of persons : *** Please note: The times that the various Shuttles will be departing, will be advised in your confirmation letter. 8 of 11

F. ATTENDANCE OF WELCOMING COCKTAIL FUNCTIO AND/OR GALA DINNER Please NOTE: SASNM apologizes in advance for any inconvenience, but for economic reasons (i.e. in order to ensure that no money is s pent on people who elect not to attend the Welcoming Cocktail Function /or the Gala Dinner), as well as th e fact that only a limited number of Delegates can be accommodated at the selected venues where the said functions will be hosted, we need to know in advance whether or not you intend attending the said functions. Therefore, attendance of these functions will be limited to ticket holders such tickets will be issued on a first confirmed, first issued basis. It is therefore of the utmost importance that you must indicate whether you a. will / will not be attending the Welcoming Cocktail Function to be hosted at the CSIR Convention Center on the evening of Friday, 10 August 2018; b. will / will not be attending the Gala Dinner Function to be hosted at the Protea Hotel Fire Ice, Menlyn, Pretoria on the evening of Saturday, 11 August 2018. G. METHOD OF PAYMENT Please NOTE: 2. SASNM apologizes in advance for any inconvenience, but for security reasons, Credit Card Payment Authorizations can will not be processed by SASNM. The only methods of payments that will be accepted are a) Direct Bank Transfers (DBT) Electronic Fund Transfers (EFT) that are made directly into SASNM s Bank Account; or b) Cheques that are made out to SA Society of Nuclear Medicine. 3. Payment is only required once your Registration has been processed an Invoice has been issued in respect thereof. However, cognizance must be taken throughout of the cut-off dates relevant to the three Registration Types. These dates will not be revised to qualify for a specific Registration Type, both your Registration Form, as well as proof of full payment, must be received by SASNM before or on the relevant cut-off date. 4. Where payments are processed electronically, the Proof of Payment must be forwarded to SASNM without delay. Such Proof of Payments must either be e-mailed to ronell.m@lantic.net, or must be faxed to +27 (0) 86 575 2334. 5. When payment is made on/following receipt of an Invoice, please quote your Invoice No as Reference to appear on SASNM s Bank Statements, as well as when forwarding your proof of payment to SASNM. 6. If one payment is made in respect of more than one Invoice, please quote as many as possible of the applicable Invoice No s as Reference to appear on SASNM s Bank Statements, but ensure that all Invoice No s are referred to when forwarding the proof of payment to SASNM. 7. If you wish to make payment prior to receipt of an Invoice, please use the Delegate/Attendee s name surname as Reference to appear on SASNM s Bank Statements, as well as when forwarding your proof of payment to SASNM. 8. As Bank charges transfer fees are for the delegate s own account, please ensure that the correct amount (in South African R value ZAR value) is transferred. 9. All electronic transfers must be made to: Bank ABSA Bank Bank Branch Menlyn Park, Menlyn Branch code 335-645 Account Holder SA Society of Nuclear Medicine Account no. 0390146736 Swift code ABSAZAJJ 9 of 11

10. For record purposes, kindly indicate which of the following methods of payment will in all probability be/have been utilized by you: Direct Bank Transfer (DBT)/Electronic Fund Transfer (EFT): I have instructed/will instruct my bank to make an electronic transfer will send you a copy of the payment documents. Cheque: I have forwarded/will forward a Cheque to SASNM, P.O. Box 70950, Die Wilgers, South Africa, 0041 will forward copies of the relevant payment documents. H. CHECK LIST/CONFIRMATIONS 1. REGISTRATION My traveling companion I / I will be attending all /some of the Lectures Sessions at the Congress as indicated in Section B above have taken cognisance of the applicable Rates cut-off dates relevant to the respective Categories for Registration; or My traveling companion I / I will NOT be attending the Lectures Sessions at the Congress have taken note that as I/we will not be paying the required Registration Fees, I/we will not be allowed into the Lecture Hall.; My traveling companion I / I will NOT be attending the Lectures Sessions at the Congress, but as indicated in Section B above, I/we will require access to all teas lunches served during the Congress have taken cognisance of the applicable Rates relevant to the respective Categories for Registration; or My traveling companion I / I will NOT be attending the Lectures Sessions at the Congress, but as indicated in Section B above, I/we will require access to the Welcoming Cocktail Function Gala Dinner events have taken cognisance of the applicable Rates relevant to the respective Categories for Registration 2. ACCOMMODATION My traveling companion I / I wish to make use of the SASNM offer relating to accommodation at the City Lodge Hotel, Lynnwood have completed Section C above requesting the reservation of accommodation for the days as specified; or My traveling companion I / I DO NOT wish to make use of the SASNM offer relating to accommodation at or in the vicinity of the Venue. 3. AIRPORT TRANSFER (SHUTTLE SERVICE): My traveling companion I / I wish to make use of the SASNM Shuttle Service for transport between the Airport the Venue have completed Section D above; or. My traveling companion I / I DO NOT wish to make use of the SASNM Shuttle Service for transport between the Airport the Venue. 4. ATTENDANCE OF WELCOMING COCKTAIL FUNCTION AND/OR GALA DINNER: I will / will not be attending the Welcoming Cocktail Function to be hosted at the CSIR Convention Center on the evening of Friday, 10 August 2018; I will / will not be attending the Gala Dinner Function to be hosted at the Protea Hotel Fire Ice, Menlyn, Pretoria on the evening of Saturday, 11 August 2018. 10 of 11

I. TERMS AND CONDITIONS Please read take careful note of the Terms Conditions referred to below. Your Registration, Accommodation Reservation Airport Transfer (whichever are applicable) will only be validated once all monies due to SASNM have been deposited into the SASNM Bank Account. No-shows will result in full fees being due to SASNM. All payments to be made payable to SASNM or transferred directly into SASNM s Bank Account proof of payments must be forwarded to ronell.m@lantic.net or must be faxed to +27 (0) 86 575 2334. All cancellations must be received in writing before 15 July 2016 a cancellation fee of 20% will be charged. Cancellations received on or after 15 July 2016 will not receive a refund. Name changes will not be accepted, unless the participant is from the same Company. All refunds will be processed after the event. Receipt of Registration Forms will (where-ever possible) be acknowledged within 5 working days of receipt thereof. CONFIRMATION OF TERMS CONDITIONS (Please delete whatever is not applicable) I, (name)... confirm as/on behalf of the Delegate/Attendee referred to in 1. above, that I have read agree to the relevant terms conditions. Signature. Date.. IMPORTANT INFORMATION VISA INFORMATION Depending on your nationality, the duration of your visit, you may need a visa to visit South Africa. For information on the basic requirements for entering South Africa, as well as comprehensive information on visas what they are, who needs them, when, where how to apply for them see the WEBSITE that can be viewed at http://www.rainbownation.com/visa/southafrica.asp. SASNM s Organizing Committee will be able to assist with invitation letters to accompany visa applications. Should you require such a letter, please send an email to amaree1@lantic.net, but kindly note that an invitation letter will only be processed once your registration has been confirmed paid for. TOURS South Africa is a tourist s dream destination. We truly offer a l of contrasts clear colors. Whether you are a lover of nature or prefer the city life, are looking for stillness or an exciting night life, wish to feast your eyes on gr lscapes or desert areas, like an excursion into the African bush or life at the coast, we can oblige you will become attached to South Africa in perpetuity. It is a country of adventure, but you don't have to be an adventurer to experience this country. A fairly well-maintained road network several airlines to choose from, makes travelling a pleasure. For tour enquiries or bookings, please contact your Travel Agent or log on to http://www.southafrica.net/sat/content/en/za/home. DEADLINES FOR REGISTRATION: Early Bird Registration 31 March 2018 Normal Registration 31 May 2018 Late Registration - 15 July 2018 www.sasnm.com 11 of 11