If you would like to receive a participation certificate for tax purposes at the tax year-end please provide us with the following details and fax them to us at 044 384 0128

Bank.............................................Branch........................................................
Branch No......................................

Account No............................................................
Type of account: ....................................................

Name of account: ...............................................................................Amount of charge - R171.00

I, (Name).............................................................................................................. authorise Matters Medical Television (Pty) Ltd to draw on my account, the annual certification fee as indicated above, on the first day of March following the date of my signature and annually thereafter until cancelled by me in writing.

Signature............................................... Date....................................

FAX THIS FORM TO: 044 384 0128