| P O Box 3704 | Tel: (011) 888-7655 | Delta Park School , |
| Randburg | Fax: 0866047124 | Standard Drive, |
| 2125 | E-Mail: adhasa@telkomsa.net | Blairgowrie, |
| Web: www.adhasa.co.za | Johannesburg |
MEMBERSHIP APPLICATION FORM ~
Annual Subscription ~ Individual R250, School R420, Professional R420
NAME: .. .. . ........................... . .
POSTAL ADDRESS: . . .......................... .
. .................................................... CODE: .. ........................... ..
TEL: (h) (.. ...) .........(w) ( .....) ........ .. CELL : .... ....... .
FAX NO: ( .) . ........ .E-MAIL: .. ............ . . .
NAME OF CHILD/MEMBER: ... ........................... . .
DATE OF BIRTH: ... ./ ./ ... .
SCHOOL: .............................. . ... ..
SIBLINGS: (Names & Ages) 1 .... 2 ........... ......... .
3 ..... .......... . . 4 ........... ..... ... . .
OCCUPATION: Mother ................................ ... .
Father .. ................................. .
May we give your name to other members in your area? Yes .. No ..
Referred to ADHASA by: .........................................................................................................
SIGNATURE: .. .. DATE: ....../ .... ./ ....
For confirmation of application kindly deposit into Standard Bank, Braamfontein Branch Code No. 004805.
Account No. 002901323 in the name of Attention Deficit & Hyperactivity Support Group of Southern Africa.
- Please make cheques payable to: ADHASA
- Cash / Cheque payments can also be made into this account
- Please use your full name as a reference
- Please fax your Application Form together with clear copy of bank deposit slip to 0866047124
- Alternatively, post this form, together with your remittance to P O Box 3704 , Randburg 2125.
Company not for gain: 93/03639/08
FOR OFFICE USE ONLY
Membership No:
Amount Paid: R . Date Paid to Bank (EFT): ...../ ...../ ..... Into Acc No: . ...
Date Chq Received in Post: ../ ../ Date Paid in Cash: ../ ../ ..
Receipt No: .. Date Pack Posted: ../ /