|
| Title |
|
| Surname: |
|
| First Name(s): |
|
| Preferred Name: |
|
| Maiden Name: |
|
| ID Number: |
|
| Postal Address line 1: |
|
| Postal Address line 2: |
|
| Postal Code: |
|
| Physical Address line 1: |
|
| Physical Address line 2: |
|
| Postal Code: |
|
| Tel (Work): |
|
| OHASA Number: |
|
| HPCSA Number: |
|
| Cell Phone: |
|
| Tel (Home): |
|
| E-Mail: |
|
| Practice: |
|
|
| Branch: |
|
| Member State: |
|
|
Important notice:
For more information regarding the Membership Categories, Fees and Benefits, please click here
|
|
| Membership Type: |
|
| International Dentistry SA Journals: |
|
|
I understand that OHASA prefers to communicate with its members and applicants via email and SMS. OHASA does not communicate with
applicants via postal service. It is therefore important that I immediately notify OHASA of any change in details i.e. email address or cellular contact number.
In order to provide you with the best possible service OHASA would like to inform you of other products, training and services within the profession.
|
| May we send you information via e-mail and sms? |
Yes
No |
| I have read, understand and agree to the provisions of the Constitution of OHASA, the Code of Conduct and the Code of Ethics and
agree to abide by the provisions thereof, including any amendments made to it from time to time |
Yes
No
|
| I have read, understand and voluntary consent to OHASA's POPIA Policy/ Notice, and the processing of my personal information in terms thereof,
including any amendments made to it from time to time.
| Yes
No |
Please email a copy of your payment and/or financial agreement to:
Email: ohasatreasurer@gmail.com
Postal Address: OHASA Secretariat
P.O. Box 830
Newlands, Pretoria
0049
BANKING DETAILS:
OHASA National
FNB Business Account
Account Number: 62837436048
Branch Code: 252445
Reference: HPCSA number, Surname
|
| Submit Form |
