APPLICATION FOR MEMBERSHIP

(Please print the following details)

TITLE:	INITIALS	FIRST NAME :	SURNAME:
ID NUMBER :
POSTAL ADDRESS :
			CODE :
TELEPHONE : ( )	Work                Home	Fax	Mobile
EMAIL : (PLEASE WRITE CLEARLY!)

PROFESSIONAL QUALIFICATIONS:

Please state your registration with HPCSA
Specialist   
Medical Practitioner

Category of registration with HPCSA (from membership card)

QUALIFICATIONS :   MMed(Anaes)           FCP           DA

SAMA number: HPCSA NO: (MP)

Of which branch of SASA would you like to be member?
*Not compulsory

Class of membership for which you are applying:

Private Practice

Full-Timer

Full-timer/LPP

Associate

Registrar

Membership Subscriptions for 2008/2009			Branch Subscriptions for 2008/2009
Private Practice	R926.00			Full	Associate
Full-timers	R654.00		Acacia	R50.00	R10.00
Full timers with LPP	R790.00		Cape Eastern	R50.00	R10.00
Associate	R790.00		Cape Western	R50.00	R10.00
Registrar	R100.00		Free State	R30.00	R30.00
(plus 14% VAT)			Gauteng South	R75.00	R15.00
			KZN	R50.00	R10.00

I HEREBY DECLARE THAT THE ABOVE INFORMATION IS TRUE AND CORRECT

SIGNATURE:	DATE:
PROPOSED BY: (Please print)	SECONDED BY: (Please print)

Proposer and seconder should be SASA members in good standing)

If accepted, I agree

• To abide by the constitution and by-laws of the Society
• To remain a member in good standing with the South African Medical Association
• To pay all subscriptions and levies as are/or may be payable
• To notify the Hon. Secretary or Hon. Treasurer of any change in qualification status, employment or address

I understand that I am not eligible to belong to any Regional Branch of the Society if I am not a member in good standing of the South African Society of Anaesthesiologists.