South African Medical Association

APPLICATION TYPE:

RULES:

TITLE:

INITIALS:

FIRST NAME(S):

SURNAME:

QUALIFICATION & QUALIFICATION YEAR, MONTH

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QUALIFICATION

Student

UNIVERISTY/COLLEGE

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CURRENT YEAR OF STUDY:

EXPECTED YEAR OF COMPLETION:

EXPECTED MONTH OF COMPLETION:

IDENTITY NUMBER:

PASSPORT NUMBER (if no ID No):

DATE OF BIRTH(YYYYMMDD):

HPCSA NUMBER:

GENDER:

RACE (used for HDI compliance):

HOME LANGUAGE:

TEL (HOME):

TEL (WORK):

CELL:

FAX:

EMAIL:

WHERE DID YOU HEAR ABOUT SAMA?:

POSTAL ADDRESS:

POSTAL POST CODE:

EMPLOYER NAME:

HOME ADDRESS:

HOME - POSTAL CODE:

RESIDENTIAL ADDRESS:

RESIDENTIAL - POSTAL CODE:

NEXT OF KIN DETAILS:

NAME:

SURNAME:

MOBILE CONTACT DETAILS:

WORK CONTACT DETAILS:

RELATIONSHIP TO MEMBER:

During 2023 I will be on

SELECT CATEGORY FROM THE LIST:

SAMA will make a nominal donation to the Benevolent Fund. Members fees are payable on a pro-rata basis if joined after Janaury

MEMBERSHIP CATEGORY:

START DATE:

SPOUSE NAME AND SURNAME:

SPOUSE SAMA NUMBER:

SPECIALITY:

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PUBLIC SECTOR:

PRIVATE SECTOR:

EDOPS SECTOR:

TYPE OF WORK:

WORK ENVIRONMENT:

PRACTICE NUMBER:

I HAVE A DISPENSING LICENCE:

PROVINCE:

PERSAL/SALARY NUMBER:

SAMA JOURNAL

I WISH TO RECEIVE THE SA MEDICAL JOURNAL(SAMJ):

JOURNAL SUBSCRIPTION RATE:

PERSAL AUTHORISATION

I hereby authorise The South African Medical Association to deduct monthly membership fees from my salary, until such time as I cancel this authorisation in writing, or until I substitute it with a new authorisation.

I declare that I am aware that SALARY AND PAY-OVER AUTHORISATION Deductions will be initialised by SAMA only.

PAYMENT METHOD:

DEBIT ORDER DETAILS:

Account holder name
Name of Bank
Branch Name
Branch Code
Account number
Account type
I, hereby request The South African Medical Association to draw against my account with the above-mentioned bank (or any other bank or branch to which I may transfer my account), the amount necessary for payment of the instalment due for my membership until further notice.
Monthly Debit Order on the next available (Month End)
Monthly Debit Order (Mid Month)
(Once off Annual) Debit Order on the next available Month End

EFT DETAILS:

BANKING DETAILS
Name: The South African Medical Association
Bank: Standard Bank, Hatfield
Acc. No.: 012577332
Branch Code: 011545
N.B. Fax proof of payment to 086 634 9656

MEMBERSHIP TERMS AND CONDITIONS:

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