|
Print, complete and fax to (021) 931-8210.
For more information email erika@saheart.org.
Please click here for
Fee Information.
| Personal details of applicant: |
| Title |
|
| First Name |
|
| Surname |
|
| Address |
|
| |
|
| City/Town |
|
| Postal Code |
|
| Tel No. |
Code: ( ) |
| Fax No. |
Code: ( ) |
| Cell No. |
|
| Email Address |
|
| I am applying for |
|
|
|
|
FULL membership |
|
ASSOCIATE membership |
| and membership of the
following REGIONAL BRANCH |
|
|
Bloemfontein |
|
Pretoria |
|
|
Cape Town |
|
Tygerberg |
|
|
Durban |
|
none |
|
|
Johannesburg |
|
|
Proposed by 1) ________________________ 2)___________________________
(The constitution stipulates that new members be proposed
by two paid up full members of SAHeart)
| I am a member of the following Special
Interest Group(s) of SAHeart |
|
|
CASSA |
|
SANCG |
|
Paediatric Cardiology Society |
|
|
Heart Failure Society HeFSSA |
|
LASSA |
|
Society for Interventional Cardiology |
|
|
| My specialty is |
|
|
Cardiologist |
|
Cardiac Surgeon |
|
|
Physician |
|
Paediatrician |
|
|
Technologist |
|
(Other, specify)_________________________ |
|
|
Nursing staff |
|
|
My special interests are (e.g. valve disease, coronary
intervention or other)
(specify)________________________________________
___________________________________
Signature
_____________________
Date
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