MEMBERSHIP APPLICATION

General Information

PUBSEC   PRIVATE   STUDENT   DOD   OTHER  

Title Please Select Mr Ms Mrs Dr Prof

Full Names

Surname

HPCSA NO.

Postal Address

Name of hospital where employed

Date of birth

Gender Male    Female

Race (Purely for statistical purposes) Please select Black White Indian Coloured Asian Other

Nationality Please select AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao, People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe

Tel (Home)

Tel (Work)

Cell

Email

Type of work Please Select Admin Clinical Lab

How did you hear about us? Please Select Website Television Radio Print media Social media Promo video Physical event Online event

Membership Category

Member fees are payable on a pro-rata basis if joined after January

Membership Category

Category	Monthly d/o	Full Year
B Intern 1st Year B Intern 2nd Year	R195.00	R2340.00
W Community Service	R265.00	R3180.00
E Fourth year after qualification	R335.00	R4020.00
D Medically qualified spouse of full member	R261.00	R3132.00
R Registrar	R335.00	R4020.00
F Full time	R452.00	R5424.00

Provide discipline

HPCSA of Spouse

Payment Method

Payment Method Debit Order   PERSAL

Persal / Force Number

Please download the debit order form below and send back to us Debit order form download here

Declaration

I would like to join the South African Medical Association Trade Union (SAMATU). I confirm that I am registered with the Health Professions Council of South Africa as a medical practitioner. I agree to abide by the SAMATU Constitution, Code of Conduct, membership terms and conditions, policies and procedures as well as any other governance documents that may regulate from time to time. I undertake to pay the monthly membership subscription fees. Information including contact information contained in the SAMATU Database as provided by you enables SAMATU to communicate (via mail, telephone, SMS, Email and fax) relevant information to you. This may from time to time include advertising of products, seminars and events. SAMATU will only send information and material that is relevant. Should you elect to receive this information, kindly indicate below. Your attention is drawn to the fact that SAMATU must, by law, disseminate certain information, such as notices of meetings and this information will be sent to you when so required.

Use of my database information: Agree    Do not agree

AUTHORITY: I/We hereby authorise you to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commences after the above-mentioned commencement date; The individual payment instructions so authorised to be issued must be issued and delivered as follows: On the above-mentioned Deduction Date of each and every month commencing on the above-mentioned commencement date. In the event that the payment day falls on a Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;I /We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher. Such must contain a number which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. This number is added to this form (SAMATU Admin Number) before the issuing of any payment instruction and communicated to me directly after having been completed by you. MANDATE: I/We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned bank as if the instructions had been issued by me/us personally. CANCELLATION: I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you ASSIGNMENT: I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The abbreviated name that will reflect on the bank statement is: SAMATU BENEFICIARY: SAMATU BENEFICIARY ADDRESS: The Corner Office, 410 Lynwood Road, Menlo Park, 0081

General Information

Title Please Select Mr Ms Mrs Dr Prof

Full Names

Surname

Postal Address

Date of birth

Gender Male    Female

Race (Purely for statistical purposes) Please select Black White Indian Coloured Asian Other

Nationality Please select AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao, People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe

Tel (Home)

Cell

Email

How did you hear about us? Please Select Website Television Radio Print media Social media Promo video Physical event Online event

Declaration

I would like to join the South African Medical Association Trade Union (SAMATU). I confirm that I am registered with the Health Professions Council of South Africa as a medical practitioner. I agree to abide by the SAMATU Constitution, Code of Conduct, membership terms and conditions, policies and procedures as well as any other governance documents that may regulate from time to time. I undertake to pay the monthly membership subscription fees. Information including contact information contained in the SAMATU Database as provided by you enables SAMATU to communicate (via mail, telephone, SMS, Email and fax) relevant information to you. This may from time to time include advertising of products, seminars and events. SAMATU will only send information and material that is relevant. Should you elect to receive this information, kindly indicate below. Your attention is drawn to the fact that SAMATU must, by law, disseminate certain information, such as notices of meetings and this information will be sent to you when so required.

Use of my database information: Agree    Do not agree

AUTHORITY: I/We hereby authorise you to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commences after the above-mentioned commencement date; The individual payment instructions so authorised to be issued must be issued and delivered as follows: On the above-mentioned Deduction Date of each and every month commencing on the above-mentioned commencement date. In the event that the payment day falls on a Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;I /We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher. Such must contain a number which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. This number is added to this form (SAMATU Admin Number) before the issuing of any payment instruction and communicated to me directly after having been completed by you. MANDATE: I/We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned bank as if the instructions had been issued by me/us personally. CANCELLATION: I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you ASSIGNMENT: I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The abbreviated name that will reflect on the bank statement is: SAMATU BENEFICIARY: SAMATU BENEFICIARY ADDRESS: The Corner Office, 410 Lynwood Road, Menlo Park, 0081