| 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 |
Student |
| UNIVERISTY/COLLEGE |
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| UNIVERISTY/COLLEGE |
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| CURRENT YEAR OF STUDY: |
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| EXPECTED YEAR OF COMPLETION: |
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| AGREE TO USE OF DATABASE INFORMATION:
NB: Information contained on the Association's database enables SAMA to communicate (mailing, telephone, SMS, e-mail, telex and facsimile) with members of the profession, keeping them informed about issues that affect them. It helps SAMA, our affiliates and our clients to select people (according to the stored criteria) to receive relevant clinical, ethical, educational and product/service information. Analysis of the information is also used for various kinds of research (including medical, economic and market research). In terms of new legislation we need your confirmation that you agree to be included for these purposes. A secion has been included in the information Update Sheet for your completion.
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| During 2017 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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Payment options:
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MEMBERSHIP CATEGORY
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Payment options:
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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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| PRIVATE SECTOR: |
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| I HAVE A DISPENSING LICENCE: |
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| PROVINCE: |
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| PERSAL/SALARY NUMBER: |
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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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