Electronic Membership Form

Membership Status (required) NewRenewal

Title (required)

Surname (required)

Initials (required)

First Names (required)

Professional Practice (required)

Degree/Qualifications (required)

HPCSA/SANC Registration (required)

Identity Number (required)

Postal Address (required)

Phone Numbers (required)

Email (required)

Annual Membership: R 350.00

Banking Details:
Bank: Standard Bank
Account Name: EMSSA
Account No: 200-491-350
Branch Code: 006-305 (Northcliff)
Reference: (Your Surname)

Please fax or email proof of payment to M Toubkin at (011) 388-2376 or admin@emssa.org.za

Please tick the box to confirm the following & enable the "Submit" button:
I am involved in education, research and/or patient care in the field of emergency medicine and wish to enroll as a member of the Emergency Mendicine Society of South Africa.

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