Membership Application Form

Please complete the form below.

Title:    
First Name: Last Name:
Institution: Division:
Position: Qualifications:
Fields of Interest: Special Interests:
Specialty in Practice: Province Registered:
HPCSA No:    
Address: Telephone:
City: Fax:
Province/State: Cellphone:
Zip/Post Code: E-mail:
Country: Website:

Notes (if any):

Annual Membership fee is:

Category
Amount
 
Total
Scientists, Clinical Technologists, Nurses, Psychologists & Counsellors
R350.00
Physicians
R600.00
Total:

Payment Options

  1. Bank Deposit: (Please fax a copy of your deposit to the secretariat)

    Name: Turners Conferences - SASRSS
    Bank: First National Bank
    Branch: Durban Main Branch
    Branch Code: 221426
    Account No: 6213 323 7299

  2. Credit Card:

    I, the undersigned, do hereby authorize Turners Conferences to debit my credit Card for the following amount:
    (please fax a copy of the front and back of your credit card to Turners)

Total Amount: (ZAR)
Cardholder:
Card No.:
Card Type:
Card Expiry Date:
Issue Number / CVC Code
3 Digit no on reverse side (where applicable)

Type this number into the box alongside: