Part B: Authorised representative and Billing details

Organisation Member Details

All details and information submitted is strictly confidential.

Registered Name of the Organisation

Trading Name

Holding Company Name (if applicable)

Organisation Registration Nr

Country of Registration

Year Registered

Year Established

Core Business of the Organisation

Postal Address

For example: SAMRA, PO Box 1713, Randburg, 2125, South Africa

Physical (Delivery) Address

For example: SAMRA, Ground Floor: Twickenham Building, The Campus, Corner Main and Sloane Street, Bryanston, Johannesburg, 2021 South Africa

Annual turnover (research suppliers) or Research budget (research users)

Please use South African Rands, and excluding VAT

Definition of Authorised Representative

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

Title

Given Names

(Include all)

Name Known As

Surname

Gender

Country of Residence

Country of Birth / Citizenship

Identity number

Birthday (mm/dd/yyyy)

Current Position

Date appointed in current position

Department

SAMRA Designated Role

Email Address

Mobile Nr

Phone Nr (Work)

The categories are mutually exclusive. Each person can only be allocated to ONE category.

Executive and senior management responsible for marketing research, social research or opinion polling research supply or use

Marketing research, social research or opinion polling research management

Marketing research, social research or opinion polling research and research-based consulting (professional level)

Data processing for marketing research, social research or opinion polling research

Data collection for marketing research, social research or opinion polling research

Individuals who have been awarded Honorary status and are on the SAMRA Honour Roll

Submission of Associate Member Details

Please submit to membership@samra.co.za 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.

SAMRA Annual fees bill to be issued in:

Title of Billing Contact

Name & Surname of Billing Contact

Designation of Billing Contact

Email Address of Billing Contact

Mobile Nr of Billing Contact

Phone Nr (Work) of Billing Contact

Fax Nr (Work) of Billing Contact

Do you require an order number for billing purposes?

VAT Nr

I hereby certify that:

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

The above organisation abides by the Southern African Marketing Research Association (SAMRA) Memorandum of Incorporation and Company Rules, and the SAMRA Code of Conduct.

I undertake, on behalf of the above organisation, to ensure payment of any fees due to SAMRA.

I understand that the organisation will remain a member of SAMRA until such time as a valid resignation is submitted to and received by SAMRA, or membership is withdrawn by SAMRA.

The above organisation meets the criteria for SAMRA Organisation Membership.

(Please indicate agreement by ticking the relevant boxes)

Part B: Authorised representative and Billing details

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