Page 39 - ONLINE – Nursing Matters October 2020_Vol 11

2021 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 | October 2020 | page 36 to http://sahivsoc.org/about/membership-application and click the “Pay Now” button. Please reference your surname and/or membership number on the payment.
HIV Nursing Matters | October 2020 | page iii
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