SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION

APPLICATION FOR MEMBERSHIP

Surname /
Title /
Full First Names
Your Usual Name
Business Address
Telephone / Code : Number:
Fax / Code : Number:
E-Mail / Cell :
Home Address
Telephone / Code : Number:
Postal Address
Name and Surname of Spouse
Title
Cell
E-Mail
Are you a member of SAMA? YES ______NO ______
I wish to apply for / Full Membership
Emeritus Membership
Associate Membership
Affiliate Membership
Extraordinary Membership / 2018 MEMBERSHIP FEES
- R5020 per annum
- N/C
- R1360 per annum
- R3130 per annum
- R3030 per annum
Date
Signature of Applicant
Proposer (Print name) and sign (must be a Full member)
Seconder (Print name) and sign(must be a Full member)

Curriculum Vitae of Applicant

Personal Details

Surname
Title
Full First Names
ID Number
Country of Birth
Date of Birth
Secondary Schooling
Name of School
Country
Year completed
Undergraduate MedicalEducation
University / Medical School
Year in Training
Degree Awarded
Year completed
Post Graduate Experience
1. Hospital
Post Held
Post Held
Dates
2. Hospital
Post Held
Dates
Post Graduate Training
University / Medical School
Year in Training
Degree / Diploma Awarded
Year Awarded
Country
Registrations
Medical Practitioner
Country
Date
Registration Number
Speciality Registration
Country
Date
Registration Number

Please complete all details. Incomplete applications CANNOT be processed and will be returned. Enclose a recent passport photograph.

Please email your completed application to or

Office Telephone : +27054338 0192 Fax: 086262 1876 Marquerite : 082490 3204

Banking details : FNB, Brandwag Branch Code : 230-534 Acc No : 58810032888

Use your Surname as a reference when you make a payment.

Please inform the SAOA office of any change of address, telephone numbers or email address. The Membership data can only be kept up to date if all changes are sent to the Secretariat.

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