Membership Renewal Form

* Required fields

Title: *Surname:
*First Name: HPCSA number:
Hospital/Centre:
Physical Address: Telephone:
Town/City: Fax:
Province: Mobile:
Postal Code: *Email:
Country: *Verify E-Mail:
Sector: Based in public/academic sector
Based in private sector
   
Notes (if any):

Category of registration and field of practice:
Ordinary - Registered Adult Nephrologist  
Ordinary - Registered Paediatric Nephrologist  
Ordinary - Specialist Physician (Internal Medicine)  
Specialist Paediatrician  
Trainee - Nephrology, Adult or Paediatric - please specify
Honorary - life-long, free
Associate - Scientist - specify field of interest and qualifications
Other Medical Practitioner - specify

Current areas of activity (please check all that apply):

I am not active at present (e.g. retired)
Clinical nephrology
Teaching nephrology
Research in nephrology

Annual Membership fee is:

MEMBERSHIP OPTION SECTION
Amount
 
Total
Ordinary SARS Membership
ZAR 3500.00
Associate SARS Membership
ZAR 1100.00
Trainee/Fellowship - 1st Year - Free
ZAR 0.00
Trainee/Fellowship - 2nd Year - 50% Member Fees
Total:

PAYMENT DETAILS

Please select your payment option below.

Option 1
Bank Transfer
Account Name:Turners Conferences and Conventions (Pty) Ltd - SA Renal Society
Bank:First National Bank
Account Type:Cheque Account
Account No.:62195900553
Branch:N1 City branch
Branch Code:200410
(Please state SARS followed by your name, on your bank transfer for fund tracking purposes)
Option 2
Credit Card
Please complete the following authorisation for Congress Organisers to debit your credit card.
A clear photocopy of both sides of the credit card is required for bank approval and verification

TOTAL AMOUNT:
Credit Card Type:
Credit Card Number
Expiry Date
Cardholder's Name
3 Digit no. on reverse side where applicable

Type this number into the box alongside: