Online International Associates Application or Existing Member Details Update Form

Personal Details

  

New Membership Application or Existing Member

Title

Initials
First Names
Surname
Date of Birth (Day, Month, Year)
National Identity Number
Postal Address
Home Postal Code
Home Telephone Number Including Area Code
Cellular Phone Number
Fax Number Including Area Code
Email Address to use for Association Notices
Photograph Available for Association Website
Personal Website (If Any)
Hobbies and Interests


Occupational Information

  
Name of Employer or Academic Institution
Work or Institution Address
Work Postal Code
Work or Institution Phone Number
Work or Institution Web Address (If Any)
Job Designation
Present Occupation
Can we contact you during working hours


Experience and Qualifications
Years of Clinical Engineering experience
A brief description of your Clinical Engineering experience and Specialised Training undertaken 
Highest Qualification achieved
Name of Qualification
Date and where Qualified
Membership of other SA Professional Associations
Membership or Reference Number
Membership of International Associations (Non-SA)
Membership or Reference Number (Non-SA)
Statutory Registration Body outside South Africa
Statutory Registration Number


Declaration and Administration
I agree to abide by the Constitution
Proposing CEASA Member (If none, leave blank)
Seconding CEASA Member (If none, leave blank)