All details and information submitted is strictly confidential.

ORGANISATION IDENTIFICATION

Registered Name of the Organisation *

AUTHORISED REPRESENTATIVE DETAILS

Please identify the new SAMRA authorised representative for the organisation. The authorised representative is the person authorised by the organisation to transact with SAMRA on behalf of the organisation. Although we communicate with all SAMRA members, the authorised representative is also the person that ALL SAMRA communications go to.

Title, Name and surname *

E.g. Mr Nelson Mandela

Phone number *

Email *

Position at Organisation *

Country of Citizenship *

Country of Residence *

Identity Number *

TERMS AND CONDITIONS

I, the authorised representative for the above organisation, hereby certify that: *

Select Yes to indicate agreement

	Yes
The information set out in this submission is true and correct to the best of my knowledge.

Authorised Representative Details (Organisation members only)

ORGANISATION IDENTIFICATION

AUTHORISED REPRESENTATIVE DETAILS

TERMS AND CONDITIONS

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