 |
Subscription
form new/renewal
Complete
the form below and submit electronically or
print, complete and post it to:
Saspen Secretariat, c/o Dept of Human Nutrition, PO Box 19063, TYGERBERG,
7505 *
or fax it to: (021) 932 9919
Membership renewal for 2005 is now due.
Please complete and return to reach the SASPEN secretariat no later than 25 February 2005.
Payment
by cheque or postal order ONLY, payable to SASPEN.
Please do not send cash
Required
fields are marked with an
* |
| Personal
details
|
Type of membership requested
New membership application
Renewal of membership |
*Title
|
*First name
|
*Surname
|
Maiden
name if applicable
|
| HPCSA registration number: MP/DT
|
*Qualifications
|
*Postal address
|
|
*Telephone office hours: Code
Number
|
| Telephone after hours: Code
Number
|
| Fax
number: Code
Number
|
| Cell
phone:
|
*E-mail address
|
Profession
|
Membership of other societies
If other, please specify
|
| Membership
fees for 2005 |
| R100,00 (Full member,
including SAJCN) |
| R70,00 (Student member,
including SAJCN) |
| R150,00 (International
member, African) |
R700,00 (International
member, European or American)
Check currency here |
| R250,00 (SAJCN member
only, not SASPEN) |
| Above fees
are applicable to your choice of membership below |
Choice of membership
you wish to subscribe to
|
Total amount you
are sending by cheque or postal order
|
| Renewal
only |
If your address has changed, please supply old address below:
|
| Were you a member
during 2004? Yes:
No:
|
| If
NO, please indicate when you were a SASPEN member:
|
| If
you have not received a membership certificate in the past, please indicate
if you would like to receive one now:
Yes |
Please
inform the secretariat immediately if your address or any other particulars
change.
See contact details at top of subscription form.
|