Page 39 - Nursing Matters June 2021 Vol 12
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2022 MEMBERSHIP APPLICATION FORM

                                              PROFESSIONAL INFORMATION

        Title:   Prof  Dr   Mr    Mrs  Ms    Initials: ____________   First Name(s): ________________________________________
        Surname: _____________________________________________  Institution/Organisation: ____________________________________
        Profession (check one):
             Doctor Generalist     Doctor Specialist     Pharmacist       Professional Nurse        Other: ___________________________________
        If Doctor Specialist, select speciality:
             Cardiology      Clinical  Pharmacology       Dermatology       Family  Physician           Infectious Diseases      OB GYN           Paediatrics
             Physician / Internal Medicine      Psychiatry     Other: _______________________________
        Council number (e.g. HPCSA, SANC): ___________________________  Practice number (if applicable): ____________________________
        Primary Employment affiliation (please chose one):
             Clinic      Government (non-clinical)       Hospital      Industry      Non-governmental Organisation (NGO)      Private Practice
             Student       University       Other
        Professional Activities (write ‘1’ for primary and ‘2’ for secondary):
             Administration       Advocacy       Patient care      Programme Management        Research      Sales/Marketing
             Teaching/Education       Other
        Please enter the year you began treating HIV patients: ___________________________________
        Please indicate if you have passed a postgraduate diploma on the clinical management of HIV from one of the following institutions:
            Colleges of Medicine of South Africa        University of KwaZulu Natal        Other: ______________________________________
              Year completed: _____________                  Year completed: _____________     Year completed: ______________
        Professional Associations:       SAMA       IAS          FIDSSA        Other: _____________________________________________


                                                 CONTACT INFORMATION
        Postal Address: ____________________________________________________________________________________________________
        _________________________   Suburb/Town: ______________________________________   Postal Code: ______________________
        Province: _____________________________________________  Country: __________________________________________________
        Telephone:____________________________________________  Mobile: ___________________________________________________
        Fax: ____________________________________ Email: ____________________________________________________________________


                                              DEMOGRAPHIC INFORMATION
        Race/ethnicity:      Black  Coloured  Indian  White   Other: _______________________________________
        Gender:     Female     Male    Intersex/Transgender        Date of Birth:           /           /

                                               MEMBERSHIP PREFERENCES

        Would you like to receive a posted copy of the Society’s magazine for nurses, HIV Nursing Matters? (Copies are available free on the Society’s
        website: www.sahivsoc.org)       Yes     No
        Would you like to participate in the Society’s online membership directory? (Your contact information will be available only to other Society
        members through the members portal on the Society’s website)       Yes     No
        How would you like to receive communications from the Society (check all that apply):      SMS      Email


         •   Doctors                                                   R400 per annum  Signed: ______________________________________
         •   Nurses & Allied Health Professionals           R300 per annum
                                                                           Date: ________________________________________
         •   Pharma Package                                R14000 per annum
            includes 10 pharma rep memberships, 2 mailers and 1 social media event / article     I hereby agree to support the values and mission of the Society;
         •   Organisation (NGO) Package                  R3500 per annum       and agree to the membership code of conduct
            for 10 staff memberships or R6000 per annum for 20 staff memberships


         Method of payment:       Electronic Transfer        Direct Deposit      Post/Cheque      Cash     Payment Date:         /       /
         Fees are now charged for a calendar year or pro rata according to the date of application. Payments may be made by cheque or electronic transfer payable to:
         Southern African HIV Clinicians Society, Nedbank Campus Square, Branch Code 158-105, Account No: 1581 048 033. For alternative online payment please go
                                                                            HIV Nursing Matters | June 2021 | page iii
         to http://sahivsoc.org/about/membership-application and click the “Pay Now” button. Please reference your surname and/or membership number on the payment.
         Please fax or email proof of payment to 011 728 1251 or [email protected] or post to: Suite 233, Post Net Killarney, Private Bag x2600, Houghton 2041.
                 HAVE QUESTIONS? Please contact us: 011 728 7365 / [email protected] / www.sahivsoc.org
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