Application for Membership: Group If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Name of your organisation * Type of membership (see constitution) Describe the main activities of your organization/group * Registration Nr (PBO/NPO/Other) Preferred language Contact person Occupation Number of group members to be registered as group members (provide details of members below) * List of Group Members Surname, initials & Title Postal address Contact numbers E-mail address Describe the benefiaries / target group of your organisation / centre Contact details for group/centre E-mail Cellular/Mobile Number Tel Fax Skype Area(s) of interest / specialisation Associations / Boards affiliate or registered with Scientific publications / Newsletters / Website Postal address Physical adress Membership fee per year for 10 members: R500.00 (minimum amount for goups) Fee per additional member (more than 10) R50.00 per year 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= *
