Application for Membership: Individual If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Title Surname * Full Name(s) * Type of membership (see constitution) Occupation Professional Boards registered with First Language Other Languages E-mail * Cellular/Mobile Number Tel Fax Skype Names of school, college, university, training centre attended and qualifications obtained Area(s) of interest / specialisation Scientific publications / presentations Postal address Home adress Work address Membership fee per year: R100.00 Donation to SASMHD Total Bank account details: Bank: ABSA Bank Name of account: The South African Society for Mental Health and Deafness (SASMHD) Account Number: 4074924791 Bank code: 632005 Swift code(international transfers): ABSAZAJJ Kindly e-mail (secretary@sasmhd.org) or sms (+27 (0) 83 633 0701) for confirmation of payment I understand that my membership will be commence only after my membership fee was received by the secretary of the SASMHD. 5+7= *
