SAMA ONLINE MEMBERSHIP APPLICATION FORM


ONLINE REGISTRATION FORM
APPLICATION TYPE:
RULES:
RULES:
RULES:
RULES:
TITLE:
INITIALS:
FIRST NAME(S):
SURNAME:
QUALIFICATION & QUALIFICATION YEAR, MONTH      add more
QUALIFICATION Student
UNIVERISTY/COLLEGE  add more
UNIVERISTY/COLLEGE  add more
CURRENT YEAR OF STUDY:
EXPECTED YEAR OF COMPLETION:
EXPECTED MONTH OF COMPLETION:
IDENTITY NUMBER:
PASSPORT NUMBER (if no ID No):
DATE OF BIRTH(YYYYMMDD):
GENDER:
RACE (used for HDI compliance):
HOME LANGUAGE:
TEL (HOME):
TEL (WORK):
CELL:
FAX:
EMAIL:
AGREE TO USE OF DATABASE INFORMATION:

POSTAL ADDRESS:


POSTAL POST CODE:

EMPLOYER NAME:




HOME ADDRESS:


HOME - POSTAL CODE:

RESIDENTIAL ADDRESS:


RESIDENTIAL - POSTAL CODE:

During 2017 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


MEMBERSHIP CATEGORY



Payment options:   

MEMBERSHIP CATEGORY



Payment options:   

SPOUSE NAME AND SURNAME:
SPOUSE SAMA NUMBER:
SPECIALITY:
   add more
PUBLIC SECTOR:
PRIVATE SECTOR:
EDOPS SECTOR:
TYPE OF WORK:
WORK ENVIRONMENT:
WORK ENVIRONMENT:
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:
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:
CONTINUE

  
Copyright © 2016 Medical Practice Consulting. All Rights Reserved. Based on TRISCOMS technology.