Individual Online Application Form
Personal Details
Membership category applied for
Choose Membership category
Associate member
Let CEASA decide for me
Full voting member
Branch preference
Choose Branch preference
Eastern Cape
Gauteng / Northern sector
Kwa-ZuluNatal
Western Cape
Title
Choose Title
Mr.
Mrs.
Miss
Doctor
Professor
Initials
First names
Surname
Date of birth (Day, Month, Year)
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 CEASA notices
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 website address (if any)
Job designation
Present occupation
Can we contact you during working hours
Yes
No
Experience and Qualifications
Years of Clinical Engineering experience
Choose CE experience
Student
Less than 2 years
2 to 5 years
5 to 10 years
10 to 15 years
15 to 20 years
More than 20 years
A brief description of your Clinical Engineering experience and specialised training undertaken
Highest qualification achieved
Choose highest qualification
High school
Student
National certificate or trade test
National diploma
Batchelors degree
Other
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)
Engineering Council of South Africa registration
Choose ECSA status
I will only register with ECSA if I have to
I intend to register with ECSA
Registered with ECSA as a CANDIDATE
Registered with ECSA as a MEDICAL EQUIPMENT MAINTAINER
Registered with ECSA as a PROFESSIONAL practitioner
Engineering Council of South Africa registration no.
Statutory registration body outside South Africa
Statutory registration number
Declaration and Administration
I agree to fully abide by the Constitution.
I understand that if I do not pay my annual fees by due date that my membership will automatically lapse and that I may then re-apply for membership at an additional cost of R 250 for reprocessing.
I agree that the onus is on me to ensure that CEASA is informed of changes in my personal contact details.
Yes
No
Proposing CEASA member (If none, leave blank)
Seconding CEASA member (If none, leave blank)
Mandatory anti-spam question
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