Focus on Health Membership Step 1 of 5 20% Personal DetailsTitle*MissMrsMrDrProfInitials*Full Name*Surname*HPCSA Registration Number*ID Number*Profession*Select your professionAmbulance Emergency AssistantBasic Ambulance AssistantBiokineticistClinical TechnologistDental AssistantDental TherapistDentistEmergency Care AssistantEmergency Care PractitionerEmergency Care TechnicianMedical Orthotist and ProsthetistMedical PractitionerOccupational TherapistOperational Emergency Care OrderlyOptometristOral HygienistsOrthopaedic Footwear TechnicianParamedicPsycho-TechnicianPsychologistPsychometristPhysiotherapistPhysiotherapy AssistantRadiographerRegistered CounsellorRestricted Supplementary Diagnostic RadiographerSupplementary BiokineticistSupplementary Dental AssistantSupplementary Diagnostic RadiographerSupplementary Occupational TherapistSupplementary Physiotherapist Contact DetailsEmail Address* Telephone No (Work)*Cell Number*Telephone No (Home)Fax NoPhysical AddressPhysical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Select if Postal Address isn't the same as Physical Address Select if Postal Address isn't the same as Physical Address Postal Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country AuditHave you received an audit letter from HPCSA?*Please Note: Extra points required for your audit will be at an additional cost.YesNoWhat audit period is stated on your audit letter?Start Date* End Date What is the due date stated on your audit letter? MM DD YYYY How many CPD points do you already have? Clinical Ethics How many points do you need to complete with Focus on Health for your Audit? Clinical Ethics Upload Audit LetterIf you can't upload your audit letter and CPD certificates now - please fax it to 086 6144 200. Drop files here or Upload CPD certificates received from other CPD providersIf you can't upload your audit letter and CPD certificates now - please fax it to 086 6144 200. Drop files here or Activities Our CPD packages for each year consist of activities to the value of either 15 or 30 CEU’s depending on your profession. Activities includes clinical and ethics activities. What calender year do you need CPD activities for?* 2015 2016 2017 2018 How would you like to receive your CPD package?*E-mailPOST to Postal addressPOST to Physical addressCourierOnline Were you referred by a member of Focus on Health*YesNoPlease provide the details of your referelFull Name First Last FoH Membership NumberSelect a payment option*Once-off paymentMonthly paymentBanking Details Bank Name: ABSA Account Type: Cheque Account Nr: 405 843 7431 Branch Code: 632 005 Ref No: HPCSA noDebit Order Details Membership runs from January to December of each year. Therefore the debit order amount will depend on the month in which you join. A membership fee of R94.05 will be added to the first month’s instalment. If applicable, the courier cost of R45.00 will also be deducted with the first month’s instalment. Thereafter only the instalments as set out below will be deducted until December 2016.When did you open your account at your Current Bank?*Bank Name*Type of Account*Account Number*Branch Code*Branch Name*Account Holders Name*Preferred Debit Order Date*1152530Abbreviated name as it will appear on your bank statement*ID Number*EmployerWhere did you hear about Focus on Health?ColleaguesFacebookFriendGoogleDo you have a promotional code?YesNoPromotional codeEnter your promotional code to receive discountAdditional commentConfirm you agree to the terms and conditions below* Focus on Health membership represents an annual subscription. Membership fees will be due and payable once Focus on Health has emailed, couriered, posted or personally delivered accredited activities to the member. When an activity is posted, a “test” envelope is included in each batch to check delivery. For the members’ convenience, membership is renewed on the last day of the applicable calendar year. Following which Focus on Health will provide the member with his/her CPD activity for that year. All membership cancellations should be submitted twenty (20) business days on or before the renewal date on 1 January of each year. Focus on Health will supply the member with his/her CPD activity via the selected delivery option and details provided above. It is the members’ responsibility to inform Focus on Health of any changes. Please contact us within 2weeks after submitting this application, if you did not receive your CPD activity. Please contact us if you did not receive your membership number via SMS within 24-36 hours.All correspondence and receipt of payments sent to Focus on Health will be confirmed via SMS to the member. Please note that when you use a promotional code to become a member, other discounts may not apply. CAPTCHA
