Application Form

MEMBER DETAILS

Title

MrMrsMissMrsDrProf

Gender

MaleFemale

First Name

Age Group

18-2425-2930-3940-4950-5960+

Surname

Date Of Birth	:
Date Of Birth	:

ID No

Language

Other

Ethnic Group:

AsianBlackColouredWhite (to assist with BEE scorecard)

Fax

:Code

[ ]

Telephone

:Code

[ ]

[]

Cell

Physical Address

Company Name

Physical Code

: []

Type of Company [area of speciality]

Postal Address

Job Title

Postal Code

: []

Region

KwaZulu NatalGautengWestern CapeEastern CapeFree StateNorth WestLimpopoMpumalangaNorthern Cape

ENTITY TO INVOICE / PAYMENT OF ACCOUNT

Name of Entity To Invoice

Name of Entity to Invoice is not listed

Do you wish invoice to be sent to member?or Accounts Contact Person?

2013 MEMBERSHIP STRUCTURE/PRICING (PLEASE INDICATE IN THE APPROPRIATE BOX)

MEMBERSHIP TYPE			2013 FEES	DISCOUNT	MEMBERSHIP FEE
	CORPORATE MEMBERSHIP (Person Specific)/INDIVIDUAL MEMBERSHIP	Per Member	R1075.00 + R150.50 VAT = R1225.50	R175 + VAT	R800 + VAT
	INDEPENDENT RETAILERS/FRANCHISEES/GOVERNMENT (Local,Provincial and National officials/employees)	Per Member	R525.00 + R73.50 VAT = R598.50	R100 + VAT	R450 + VAT
	STUDENT MEMBERSHIP/25 YEAR OLD/PENSIONER MEMBER	Per Member	R325.00 + R45.50 VAT = R370.50	R50 + VAT	R250 + VAT

Do you wish to receive:

Info in areas of interestInfo only related to your regionAll infoNone

Once the application form has been recieved with all the fields completed , an invoice will be generated and sent to the member / account contact for payment

I undertake to abide by the Council’s Constitution.

and the form will be e-mailed to membership@sacsc.org.za.