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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INITIALS: |
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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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EXPECTED MONTH OF COMPLETION: |
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IDENTITY NUMBER: |
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PASSPORT NUMBER (if no ID No): |
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DATE OF BIRTH(YYYYMMDD): |
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HPCSA NUMBER: |
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GENDER: |
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RACE (used for HDI compliance): |
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HOME LANGUAGE: |
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TEL (HOME): |
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TEL (WORK): |
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CELL: |
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FAX: |
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EMAIL: |
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POSTAL ADDRESS: |
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POSTAL POST CODE: |
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EMPLOYER NAME: |
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HOME ADDRESS: |
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HOME - POSTAL CODE: |
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RESIDENTIAL ADDRESS: |
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RESIDENTIAL - POSTAL CODE: |
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During 2019 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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PRIVATE SECTOR: |
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EDOPS SECTOR: |
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TYPE OF WORK: |
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WORK ENVIRONMENT: |
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WORK ENVIRONMENT: |
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WORK ENVIRONMENT: |
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PRACTICE NUMBER: |
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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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