Registration Form for New Members

Personal details of applicant

Title
First Names
Surname
Address
Town
Code
Tel	Code
Fax	Code
e- mail
cellphone
MP number
I am connected to the following hospital/s

I am applying for

FULL membership (Cardiologists, Surgeons, Paediatricians, Physicians)

ASSOCIATE membership (all other allied professionals)

- and membership of the following REGIONAL BRANCH

Cape Town	Durban	Johannesburg	Pretoria

Tygerberg	Bloemfontein	none

Proposed by:	1) ________________________ 2)___________________________

(The constitution stipulates that new members be proposed by two paid up full members of SAHeart)

I am a member of the following Special Interest Group(s) of SA Heart

CASSA (Arrhythmia)	SASCAR (Research)	PCSSA (Paediatric)	CISSA (Imaging)

Surgical Interest Group	SASCI (Interventional)	LASSA	HeFSSA (Heart failure)

My specialty/qualification is

Cardiologist	Physician	Cardiac Surgeon	Paediatrician	Nursing staff

General Practitioner	Technologist	Radiographer	Research	Industry

__________________________ (Other, specify)

My special interest is: (e.g. valve disease, coronary intervention or other)

____________________________________________________________(specify)

___________________________________	_____________________

Signature	Date