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Surname
Title
Full First Names
Your Usual Name
Name of Spouse
Business Address
Telephone	Code Number
Fax	Code Number
E-mail
Cell:
Home Address
Telephone	Code Number
Postal Address
I wish to apply for	Full Membership Emeritus Membership Associate Membership Affiliate Membership Extraordinary Membership
Date
Signature of Applicant
Proposer (Print name and signed by a full member)
Seconder (Print name and signed by a full member)
Cirriculum 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 Medical Education
University / Medical School
Year in Training
Degree Awarded
Year completed
Post Graduate Experience
1. Hospital
Post Held
Dates
2. Hospital
Post Held
Dates
3. 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. Enclose a recent passport photograph. Return the original application form to the following address.
The Administrative Secretary PO Box 12918 BRANDHOF 9324 Telephone: +27 51 430 3280 Fax: +27 51 430 3284 E-mail: saoa@connix.co.za	FOR OFFICE USE Date: Application Received ................................................. Application Acknowledged ........................................ Date Elected .............................................................. Date Notified ............................................................. Membership Booklet Posted ...................................... Membership Certificated Posted ............................... Computerised ............................................................. Correspondence Returned .........................................
Please inform the Administrative Secretary of any change of address or telephone numbers. The Membership data can only be kept up to date if all changes are sent to the Secretariat.

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