Membership Renewal Form - South African Nephrology Society

Membership Renewal Form

* Required fields

Title:		*Surname:
*First Name:		HPCSA number:
Hospital/Centre:		Date of birth:
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 SANS Membership (Includes ISN Fee)	ZAR 3850.00
Associate SANS Membership	ZAR 1210.00
1^st Year Trainee/Fellow (Includes ISN Fee)	ZAR 0.00
2^nd & 3^rd Year Trainee/Fellow (Includes ISN Fee)	R1925 (50% Membership fees)
Corporate Membership	R 22 000.00
Honorary Life Members	Free
Total:

I agree to abide by the Charter of members of SANS (Charter available here)

Please select your payment option below.

Option 1
Bank Transfer

Account Name:	Turners Conferences and Conventions (Pty) Ltd - South African Nephrology Society
Bank:	First National Bank
Account Type:	Cheque Account
Account No.:	62195900553
Branch:	N1 City branch
Branch Code:	200410

(Please state SANS followed by your name, on your bank transfer for fund tracking purposes)

Option 2
Credit Card

TOTAL AMOUNT:

Type this number into the box alongside: