Membership Application 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:
Registered Adult Nephrologist  
Registered Paediatric Nephrologist  
Specialist Physician  
Specialist Paediatrician  
Trainee in Nephrology, Internal Medicine or Paediatrics - please specify
Other Medical Practitioner - specify
Scientist - specify field of interest

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

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

Annual Membership fee is:

MEMBERSHIP OPTION SECTION
Amount
 
Total
Full/Ordinary SARS ONLY Membership 2016:
ZAR 350.00
Trainee SARS Member ONLY 2016:
ZAR 250.00
Full/Ordindary SARS and ISN Membership 2016:
ZAR 2350.00
Trainee SARS and ISN Membership 2016:
ZAR 2250.00
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: