| APPLICATION TYPE: |
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| RULES:
By completing this application form I confirm that I would like to join the South African Medical Association. And that I am registered with the Health Professions Council of South Africa as a medical student. I agree to abide by the Memorandum of Incorporation and Company Rules of the Association.
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| RULES:
By completing this application form I confirm that I would like to join the South African Medical Association. And that I am registered with the Health Professions Council of South Africa as a medical intern/practitioner. I agree to abide by the Memorandum of Incorporation, Company Rules and Trade Union Constitution of the Association, and undertake to pay the prescribed subscription annually.
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| RULES:
By completing this application form I confirm that I would like to join the South African Medical Association. And that I am registered with the Health Professions Council of South Africa as a medical practitioner. I agree to abide by the Memorandum of Incorporation and Company Rules of the Association, and undertake to pay the prescribed subscription annually.
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| RULES:
By completing this application form I confirm that I would like to join the South African Medical Association. And that I am registered with the Health Professions Council of South Africa as a medical practitioner. I agree to abide by the Memorandum of Incorporation and Company Rules of the Association, and undertake to pay the prescribed subscription annually.
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| TITLE: |
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| FIRST NAME(S): |
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| SURNAME: |
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| QUALIFICATION & QUALIFICATION YEAR, MONTH |
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| QUALIFICATION |
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| UNIVERISTY/COLLEGE |
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| UNIVERISTY/COLLEGE |
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| CURRENT YEAR OF STUDY: |
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| DATE OF BIRTH(YYYYMMDD): |
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| SAMA NUMBER: |
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| During 2018 I will be on |
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| 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
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MEMBERSHIP CATEGORY
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MEMBERSHIP CATEGORY
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| START DATE |
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| SPOUSE NAME AND SURNAME: |
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| SPOUSE SAMA NUMBER: |
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| SPECIALITY: |
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| PUBLIC SECTOR: |
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| I HAVE A DISPENSING LICENCE: |
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| PROVINCE: |
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| SAMA JOURNAL |
I WISH TO RECEIVE THE SA MEDICAL JOURNAL(SAMJ):
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| JOURNAL SUBSCRIPTION RATE: |
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| 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.
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| PAYMENT METHOD: |
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| DEBIT ORDER DETAILS: |
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| 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
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| MEMBERSHIP TERMS AND CONDITIONS: |
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CONTINUE
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