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Part B: Authorised representative and Billing details

Organisation Member Details
For example: SAMRA, PO Box 1713, Randburg, 2125, South Africa
For example: SAMRA, Ground Floor: Twickenham Building, The Campus, Corner Main and Sloane Street, Bryanston, Johannesburg, 2021 South Africa
Please use South African Rands, and excluding VAT

The authorised representative is the person authorised by the organisation to transact with SAMRA on behalf of the organisation

(Include all)

Please submit to the SAMRA template containing the data for all workers/employees at your organisation who are in SAMRA Designated Roles as at date of submission here (see link at the top of this form). On this list, you can also include temporary workers/employees as well as any contractors and/or freelancers that are doing work for you in any of the SAMRA Designated Roles, and that you would like to nominate for Associate membership under your organisation, in addition to the permanent employees as counted above. As a minimum requirement, all permanent workers/employees included in the headcount used for billing (above) must be included as they will be Associate Members.

(Please indicate agreement by ticking the relevant boxes)