Surname

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First Names

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Identity number

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Qualifications

Occupation

Postal Address

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Code

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E-mail :

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Tel No (H) :

Tel No (W) :

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Fax:

Mobile:

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My choice of communication:

Mobile or Email Address

Post

WHASA Membership Number (if applicable)

WHASA Region
(select province by marking appropriate block)

Choose a Region... Eastern Cape. Free State. Gauteng. Kwazulu-Natal. Mpumalanga. North West. Western Cape. Limpopo. Northern Cape.

Please register me for (select your option in the allocated blocks on left side of table)

Total amount

PAYMENT DETAILS:

Please deposit the amount relevant to your selection into the WHASA bank account and include the proof of payment with your application form.

WHASA Banking Details

Bank : Standard Bank
Branch : Brooklyn
Branch Code: 011245
Account No : 012966622

For other methods of payment, please call us at : 011-475-2902 or via e-mail at membership@whasa.org