MEMBERSHIP APPLICATION FORM 2017

CONTACT DETAILS

Name:
Tel: / Cell: / Email:
Address:
City: / Region: / ZIP Code:
Short description of practice:

AFFILIATIONS

BHF no.: / HPCSA no.: / AHPCSA no.:
Are you a member of SA Medical Association?

Qualifications

Qualifications and Training: / Year:

MODALITIES

Please mark in bold which of the following you incorporate in your practice:
Acupuncture / Homeopathy / Orthomolecular medicine
Anthroposophic medicine / Homotoxicology / Ozone therapy
Anti-aging medicine / Hypnotherapy / Prolotherapy
Ayurvedic medicine / Intravenous therapy / PNI
Biopuncture / Kinesiology / Rife Resonator therapy
BEMER therapy / Laser therapy / TCM
Bio-energetic tools / Lifestyle modification / Trauma releasing exercise
Chelation / Live blood analysis / VoiceBio
Energy healing / Mindfulness-based medicine / Western medicine
Functional medicine / Naturopathy / Other*
*Please specify:

Signatures

Do you wish to have your details, as given above, advertised on the SASIM website?
Signed: / Date:
Please name 2 colleagues who are willing to vouch for you:
1. / Contact no.:
2. / Contact no.:

MEMBERSHIP CATEGORIES

1. Medical members / Medical doctors registered with HPCSA @ R750 p.a
2. Allied members / Allied Doctors registered with the AHPCSA, psychologists and biological dentists registered with the HPCSA, Veterinary Council registered vets, Nursing Council registered nurses @ R600 p.a
3. Associates / Unregistered doctors, nutritional therapists, foreign/unregistered MDs, other practitioners @ R600 p.a
4. Students / R300 p.a
A once-off registration fee of R200 applies to categories 1, 2 and 3, for new registrations.
Please state the membership category relevant to you:

Banking details

Payment can be made into the account below:
·  SASIM
·  Nedbank, Stellenbosch
·  Branch code: 135705
·  Account number: 1357 003986

NOTEs

Please complete this application form on your computer, type in your signature – or use your digital one - and send to our administrator, Elma Pollard, together with your proof of deposit.
Tel: 021-8550518 / Email:
This information will not be given out to any other party, nor will it appear on any website other than our own. Membership is subject to the approval of the Committee.