
	:: Vision & Mission

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	:: Executive and Council

	:: Past Executive

	:: Membership

	:: Membership Fees

	:: Centers of Excellence

	:: User Name and Password

	:: Contact Us

Membership Form

Please note that once the below online form has been completed you will be charge the full yearly registration fee.
If you would like to be billed monthly then please download the registration form and fax your completed details to 011 782 0270.
Click here to download the Registration Form.

* Indicates required fields are compulsory.

Title:	*
Surname:	*
First Name:	*
Postal Address:	*
City:	*
Postal Code:	*
Practice Address:	*
Street:	*
Town:	*
Practice Number:	*
HPSA Reg. Number:	*
Identity Number:	*
Are you paid up member of SAMA:	Yes	No

PRACTICE DETAILS

Practice Telephone:	( ) *
Practice Fax:	( ) *
Cellular Phone:	*
E-Mail Address:	*
Hospital at which you practice(include day clinics and Medicross)
Name of partners and associates(indicateP/A)
Do you qualify as a:	Private Practitioner
	Fee - R2 394 + R342 Special Levy - Emergency Fund = R2 736 (VAT inclusive)

	Public Service
	Fee - R570 + R57 Special Levy - Emergency Fund = R627 (VAT inclusive)

Anti-spam	Sum of 10 + 2 ?

SASOG Banking Details
GMG Ltd
Nedbank Killarney
Branch Code: 191605
Account No: 1916 053726

Click here to download the Registration Form.

Last Updated: 2 Nov 2009