MEMBERSHIP APPLICATION

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Title Please Select Mr Ms Mrs Dr Prof

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HPCSA NO.

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Province Please select province GAUTENG WESTERN CAPE EASTERN CAPE KWAZULU-NATAL LIMPOPO MPUMALANGA FREE STATE NORTH WEST NORTHERN CAPE

Hospital Please select hospital LAETITIA BAM COMMUNITY HEALTH CENTRE S S GIDA HOSPITAL ST BARNABAS HOSPITAL 1 MILITARY 3 MILITARY ABERDEEN ADDINGTON HOSPITAL ADELAIDE HOSPITAL ALBERT NZULA DISTRICT ALEXANDRA HOSPITAL ALIWAL NORTH HOSPITAL ALL SAINTS HOSPITAL AMAJUBA MEMORIAL ANDRIES VOSLOO HOSPITAL BAMBISANA HOSPITAL BARBERTON BARKLEY WEST BAZIYA C H C BEATRICE NGWENTLT CLINIC BEAUFORT WEST HOSPITAL BEDFORD HOSPITAL BEDFORD ORTHOPAEDICS BENEDICTINE HOSPITAL BERNICE SAMUEL BERTHA GXOWA BETHAL BETHESDA HOSPITAL BHEKI MLANGENI BILL PICKARD BISHO DISTRICT HOSPITAL BJ VOSTER HOSPITAL BOIKHUTSONG CHC BOITUMELO BOJANALA DISTRICT OFFICE BONGANI BOPHELONG PSYCHIATRIC BOTLOKWA HOSPITAL BOTSHABELO BRITS BRONKHORSTSPRUIT BROOKLYN CHESTHOSPITAL BROWNS FARM COMMUNITY HEALTH CENTRE BUFFALO CITY SUB DISTRICT BURGERSDORP HOSPITAL BUTTERWORTH HOSPITAL CALA PROVINCIAL HOSPITAL CANZIBE PROVINCIAL HOSPITAL CARLETONVILLE CAROLINA CATHCART DISTRICT HOSPITAL CATHERINE BOOTH HOSPITAL CECILIA MAKIWANE HOSPITAL CERES HOSPITAL CEZA HOSPITAL CHARLES JAMES HOSPITAL CHARLES JOHNSON MEMORIAL HOSPITAL CHARLOTTE MAXEKE CHATTY CLINIC CHIAWELO CHC CHRIS HANI BARAGWANATH CHRIST THE KING HOSPITAL CHRISTIANA DISTRICT CHURCH OF SCOTLAND HOSPITAL CLAIRWOOD HOSPITAL CLANWILLIAM HOSPITAAL CLOCOLAN/ HLOHLOLWANE CLOETE JOUBERT HOSPITAL COFIMVABA PROVINCIAL HOSPITAL CONNIE VORSTER CRADOCK HOSPITAL DE AAR DELARAYVILLE CHC DELFT COMMUNITY HEALTH CENTRE DIAMANT DISTRICT DIHLABENG DILOKONG HOSPITAL DIMBAZA COMMUNITY HEALTHCARE CENTRE DIRECTORATE HEALTH SUPPORT DISCOVERERS DLANGUBO CLINIC DOBSONVILLE CHC DON MCKENZIE HOSPITAL DONALD FRASER HOSPITAL DONDOTHA CLINIC DORA NGINZA HOSPITAL DORDRECHT HOSPITAL DORIS GOODWIN HOSPITAL DP MARAIS HOSPITAL DR CN PHATUDI HOSPITAL DR GEORGE MUKHARI DR J.S MOROKA DR KENNETH KAUNDA DISTRICT OFFICE DR MALIZO MPEHLE MEMORIAL HOSPITAL DR PIXLEY KA ISAKA SEME MEMORIAL HOSPITAL DR VAN NIEKERK DR YUSUF DADOO DUNCAN VILLAGE DAY HOSPITAL DUNDEE HOSPITAL DUTYWA COMMUNITY HEALTH CARE CENTRE EAST BOOM COMMUNITY HEALTH CENTRE EAST LONDON HOSPITAL COMPLEX EASTERN CAPE DEPARTMENT OF HEALTH HEAD O EASTLYNNE CHC EDENVALE EDUMBE COMMUNITY HEALTH CENTRE EERSTE RIVER HOSPITAL EERSTERUST CHC EKOMBE HOSPITAL EKUPHUMULENI CLINIC EKURHULENI HEALTH DISTRICT ELIM HOSPITAL ELIZABETH DONKIN HOSPITAL ELIZABETH ROSS DISTRICT ELLIOT HOSPITAL ELLISRAS DISTRICT HOSPITAL ELLISRAS HOSPITAL ELSIE BALLOT ELSIES RIVER COMMUNITY HEALTH CENTRE EMBEKWENI EMBHULENI EMMAUS DISTRICT HOSPITAL EMPILISWENI HOSPITAL EMPILWENI GOMPO HEALTH CARE ENOCH MGIJIMA COMMUNITY HEALTH CENTRE ERMELO ESHOWE DISTRICT HOSPITAL ESHOWE HOSPITAL ESTCOURT HOSPITAL EVANDER EVUXAKENI DISTRICT HOSPITAL FAR EAST RAND FEZI NGUBENTOMBI FH ODENDAAL HOSPITAL FLAGSTAFF COMMUNITY HEALTH CENTRE FOLANG CHC FORENSIC PATHOLOGY SERVICES UCT FORENSIC PATHOLOGY SERVICES US FORT BEAUFORT PROVINCIAL HOSPITAL FORT ENGLAND PSYCHIATRIC HOSPITAL FORT GREY SANTA TB HOSPITAL FORT NAPIER HOSPITAL FRERE TERTIARY HOSPITAL FRITZ VISSER FRONTIER HOSPITAL GALESHEWE GAMALAKHE COMMUNITY HEALTH CENTRE GANYESA DISTRICT GELUKSPAN GENERAL DE LA REY GENERAL JUSTICE GIZENGA MPANZA REGIONAL HOSPITAL GEORGE HOSPITAL GEORGE MASEBE HOSPITAL GJ CROOKES HOSPITAL GJ JOOSTE HOSPITAL GLEN GREY HOSPITAL GOOD HOPE COMMUNITY HEALTH CENTRE GOODWOOD COMMUNITY HEALTH CENTRE GORDONIA GRAAF REINET DISTRICT HOSPITAL GRAAFF REINET CHC GREEN POINT COMMUNITY HEALTH CENTRE GREENVILLE PROVINCIAL HOSPITAL GREY HOSPITAL GREYTOWN HOSPITAL GREY`S HOSPITAL GROBLERSDAL HOSPITAL GROOTE SCHUUR HOSPITAAL GUGULETU COMMUNITY HEALTH CENTRE H A GROVE HANOVER PARK COMMUNITY HEALTH CENTRE HARRY COMAY HOSPITAL HARRY GWALA REGIONAL HOSPITAL HARRY SURTIE HAYANI PSYCHIATRIC HOSPITAL HEIDEDAL CHC HEIDELBERG HELDERBERG HOSPITAL HELEN JOSEPH HELENA FRANZ HOSPITAL HERMANUS HOSPITAL HESTER MALAN HEWU HOSPITAL HLABISA HOSPITAL HOLY CROSS HOSPITAL HOTTENTOTS HOLLAND HOSPITAL HUMANSDORP HOSPITAL IDUTYWA VILLAGE COMMUNITY HEALTH CENTRE IMBALENHLE CLINIC IMPUNGWE INANDA COMMUNITY HEALTH CENTRE INKOSI ALBERT LUTHULI CENTRAL HOSPITAL ITIRELENG CHC ITSHELEJUBA HOSPITAL ITSOSENG SUB-DISTRICT JAMESTOWN HOSPITAL JANE FURSE HOSPITAL JHB METRO FAMILY MEDICINE JOB SHIMANKANA TABANE JOE MOROLONG JOSE PEARSON TB HOSPITAL JOUBERTINA COMMUNITY HEALTH CENTRE JOZINI COMMUNITY HEALTH CENTRE JUBILEE KALAFONG KARL BREMER HOSPITAL KATLEHO DISTRICT KENSINGTON COMMUNITY HEALTH CENTRE KESS COMMUNITY HEALTH CENTRE SITE B KGAPANE HOSPITAL KHAYELITSHA DISTRICT HOSPITAL KHOTSONG TB HOSPITAL KING DINIZULU HOSPITAL KING EDWARD VIII HOSPITAL KLERKSDORP/TSHEPONG KNYSNA HOSPITAL KOMGA HOSPITAL KOPANONG KORSTEN CHC KOSTER KOUGA SESSIONAL DOCTORS KRAAIFONTEIN COMMUNITY HEALTH CENTRE KURUMAN KWAMASHU COMMUNITY HEALTH CENTRE KWAMHLANGA KWAZAKHELE CLINIC LADYSMITH HOSPITAL LANGA COMMUNITY HEALTH CENTRE LAUDIUM LEBOWAKGOMO HOSPITAL LEJWELEPUTSWA CHC LENASIA LENTEGEUR HOSPITAL LERATONG LETABA HOSPITAL LETLHABILE CHC LILLIAN NGOYI CHC LIVINGSTONE HOSPITAL LIVINGSTONE TERTIARY HOSPITAL LOUIS TRICHARDT MEMORIAL HOSPITAL LOWER UMFOLOZI DISTRICT WAR MEMORIAL HOS LYDENBURG MACASSAR COMMUNITY HEALTH CENTRE MACLEAR HOSPITAL MADADENI HOSPITAL MADZIKANE KAZULU MEMORIAL HOSPITAL MAFIKENG MAFUBE DISTRICT MAHATMA GANDHI HOSPITAL MAJORIE PARRISH TB HOSPITAL MAKAPANSTAND CHC MALAMULELE HOSPITAL MAMELODI MAMETLHAKE MANGUZI HOSPITAL MANKWENG HOSPITAL MANTSOPA DISTRICT MAPHUTHA L MALATJI HOSPITAL MAPHUTHA MALATJIE MAPULANENG MARTJE VENTER MATIBIDI MATIKWANA MATLALA HOSPITAL MBONGOLWANE DISTRICT HOSPITAL MCCORD HOSPITAL MDR TB CLINIC MECKLENBURG HOSPITAL MFUNDO ARNOLD LUSHABA COMMUNITY HEALTH CENTRE MIDDELBURG MITCHELLS PLAIN DISTRICT HOSPITAL MJANYANA HOSPITAL MOFOLO CHC MOFUMAHADI MANAPO MOPELI MOGWASE CHC MOHAU MOKOPANE HOSPITAL MONTEBELLO HOSPITAL MONTSIOA STAD CHC MORETELE MORNING STAR COMMUNITY HEALTH CENTRE MOSES KOTANE MOSSEL BAY HOSPITAL MOSVOLD HOSPITAL MOTHERWELL COMMUNITY HEALTH CENTRE MOUNT AYLIFF HOSPITAL MOWBRAY MATERNITY HOSPITAL MSELENI HOSPITAL MTHATHA GENERAL HOSPITAL MTHATHA HOSPITAL MURCHISON HOSPITAL MUSINA HOSPITAL NALA NATIONAL DISTRICT NDWEDWE COMMUNITY HEALTH CENTRE NELSON MANDELA ACADEMIC HOSPITAL NELSON MANDELA CHILD HOSPITAL NESSIE KNIGHT HOSPITAL NEW SOMERSET NEWCASTLE HOSPITAL NEWTOWN COMMUNITY HEALTH CENTRE NGCOBO SUB DISTRICT NGWELEZANA HOSPITAL NIEMEYER HOSPITAL NKANDLA HOSPITAL NKHENSANI HOSPITAL NKONJENI HOSPITAL NKQUBELA TB HOSPITAL NOMPUMELELO HOSPITAL NONTYATYAMBO COMMUNITY HEALTH CLINIC NORTHDALE HOSPITAL NORTHERN CAPE MENTAL HEALTH INSTITUTION NSELENI COMMUNITY HEALTH CENTRE ODI OLIVER AND ADELAIDE TAMBO REGIONAL HOSPITAL ORSMOND TB HOSPITAL OSINDISWENI HOSPITAL OTHOBOTHINI COMMUNITY HEALTH CENTRE OUDTSHOORN HOSPITAL PAARL HOSPITAL PARK RYNIE FORENSIC PATHOLOGY MORTUARY PAROW COMMUNITY HEALTH CENTRE PARYS DISTRICT PELLA CHC PELONOMI PHEKOLONG DISTRICT PHILADELPHIA HOSPITAL PHOLELA COMMUNITY HEALTH CENTRE PHOLOSONG PHOMOLONG CHC PHUTHULOHA PIET RETIEF POLOKWANE/MANKWENG HOSPITAL COMPLEX POLOWKANE PROVINCIAL HOSPITAL POMEROY COMMUNITY HEALTH CENTRE PORT ELIZABETH PROVINCIAL HOSPITAL PORT SHEPSTONE HOSPITAL POSTMASBURG POTCHEFSTROOM PRETORIA WEST PRINCE MSHIYENI MEMORIAL HOSPITAL PZ MEYER TB HOSPITAL QUEEN NANDI REGIONAL HOSPITAL R K KHAN HOSPITAL RADIE KOTZE HOSPITAL RAHIMA MOOSA RAMOTSE CHC RATLOU CHC RAVENSMEAD COMMUNITY HEALTH CENTRE RED CROSS HOSPITAL RETHABILE COMMUNITY HEALTH CENTRE RETREAT COMMUNITY HEALTH CENTRE RICHMOND HOSPITAL RIETVLEI DISTRICT HOSPITAL ROB FERREIRA ROBERT MANGALISO SOBUKWE ROBERTSON HOSPITAL ROSEDALE CLINIC SABIE SAWAS MEMORIAL HOSPITAL SCHWEIZER SEBOKENG SEDIBENG SEKORORO HOSPITAL SENORITA NHLABATHI SESHEGO HOSPITAL SETTLERS HOSPITAL SHONGWE SILOAM HOSPITAL SIPETU HOSPITAL SIZWE TROPICAL DISEASE SOUTH RAND SS GIDA DISTRICT HOSPITAL ST AIDANS HOSPITAL ST ANDREWS HOSPITAL ST CHADS COMMUNITY HEALTH CENTRE ST ELIZABETH REGIONAL HOSPITAL ST ELIZABETH`S HOSPITAL ST MARGARETS DISTRICT HOSPITAL ST MARY'S KWAMAGWAZA HOSPITAL ST MARYS MARIANHILL HOSPITAL ST PATRICKS HOSPITAL ST RITA'S HOSPITAL ST. LUCY'S PROVINCIAL HOSPITAL STANDERTON STANGER HOSPITAL STELLENBOSCH HOSPITAL STERKFONTEIN STERKSTROOM PROVINCIAL HOSPITAL STEVE BIKO STEYNSBURG HOSPITAL STIKLAND HOSPITAL STOFFEL COETZEE DISTRICT STUTTERHEIM HOSPITAL SUNDAYS RIVER HOSPITAL SWARTLAND HOSPITAL SWARTRUGGENS SWELLENDAM HOSPITAL SYMPHONY WAY CLINIC TAFALOFEFE HOSPITAL TAMBO MEMORIAL TARA TAUNG DISTRICT HOSPITAL TAYLER BEQUEST HOSPITAL TC NEWMAN HOSPITAL TEMBISA THABAMOOPO PSYCHIATRIC HOSPITAL THABAZIMBI DISTRICT HOSPITAL THEBE THELLE MOGOERANE THEMBA THUSANONG DISTRICT TINTSWALO TOKOLLO DISTRICT TONGA TOWER HOSPITAL TOWN HILL HOSPITAL TSABALETSHUBA HEALTH CENTRE TSHILIDZINI HOSPITAL TSHWANE DISTRICT TSHWARAGANO TSWANE REHAB TYGERBERG HOSPITAAL UITENHAGE DISTRICT HOSPITAL UMGENI MIDLANDS HOSPITAL UMGUNGUNDLOVU DISTRICT MEDICAL OFFICE UMLAMLI HOSPITAL UMPHUMULO HOSPITAL UMZIMKULU HOSPITAL UNIVERSITAS UNTUNJAMBILI HOSPITAL VALKENBERG HOSPITAL VAN VELDEN HOSPITAL VENTERSDORP VICTORIA HOSPITAL VOORTREKKER DISTRICT HOSPITAL VOORTREKKER HOSPITAL VREDENDAL HOSPITAL VRYBURG DISTRICT HOSPITAL VRYHEID DISTRICT HOSPITAL WARMBATHS HOSPITAL WARRENTON WATERVAL- BOVEN WENTWORTH HOSPITAL WESFLEUR HOSPITAL WESKOPPIES WESTERN CAPE REHABILITATION CENTRE WESTRAND DISTRICT CLINIC WF KNOBEL HOSPITAL WILLOWMORE HOSPITAL WINNIE MADIKIZELA MANDELA SUBDISTRICT WITBANK WITPOORT HOSPITAL WITRAND PROVINCIAL WOLMARANSTAD DISTRICT OFFICE WORCESTER WYNBERG MEWS COMMUNITY HEALTH CENTRE ZEBEDIELA HOSPITAL ZEERUST ZITULELE HOSPITAL ZOLA ZWIDE CLINIC

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

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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

Work 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