COR051
INDIVIDUAL STUDENT MEMBERSHIP APPLICATION FORM
Individual Student applicant Information:
Surname
First Names
Mr, Ms, Miss, Prof, Dr,
Title
Designatory
Country
Business
Fax No.
Home No.
Mobile
Date of Birth
Email
Email Work
Physical
Address
Postal
Address
e.g. BSc, CEng, MIMF, Secretary
Code
Code
Employer Information:
Company
Dept.
Position
Acc Email
Work No.
Fax No.
Physical
Address
Postal
Address
Code
Conferences
Annual Dinners
Code
Which event would be of interest to you? (Please Tick)
Technical Evenings
How to Days
Golf Events
Fishing Events
Other - Specify
Plant Visits
Gauteng
General Interest:
CONSTRUCTION/MANUFACTURER:
ASSET OWNER/END USER:
ASSOCIATION:
Chemistry
Metallurgy
Engineering
OTHER – Specify below
Cathodic Protection Products
SUPPLIER
Cathodic Protection
Application
Corrosion Consulting
Labs and Testing
Quality Control
Training
OTHER – Specify below:
SET SKILL
SERVICE PROVIDER
How would you best describe your business? (Select only one)
Application Products
Coating Material
GENERAL – Specify below:
Which region would you select? (Please Tick)
For mailing purposes, we will allocate you to your home region unless otherwise specified.
Kwa Zulu Natal
Western Cape
Other - Specify
APPLICANT'S DECLARATION: (See the By-laws to the Constitution)
I do hereby apply to be admitted as an Individual Student Member of the Corrosion Institute of Southern Africa, and I do solemnly and
sincerely declare that in the event of my election as an Individual Student Member of the Institute, I will at all times observe the provisions of
the constitution and the By-laws thereof and will conduct myself honourably in the practice of my profession, and to the utmost of my power
will maintain the dignity and welfare of the Institute, by adhering to the code of ethics as defined in the Constitution.
YES
NO
Email notification allowed
YES
Name
Date
Signed at
Signature
Version: 1
Revision Date: May 2017
NO
SMS notification allowed
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COR00
MEMBERSHIP FEE STRUCTURE
Annexure A
MEMBERSHIP FEES FOR 2016/2017
ANNUAL SUBSCRIPTIONS
(Note: New Members include once off admin fee)
CATEGORY
FEE
Including VAT
Individual member
R440.00
R501.60
Fellow member
R550.00
R627.00
Student Member
R165.00
R188.01
Universities
R2090.00
R2382.26
Company member
R3300.00
R3762.00
Honorary Life Member
Nil
Nil
Retired Member
Nil
Nil
CATEGORY
FEE
Including VAT
R250.00
R285.00
Once off Admin Fee for New Members Only
Banking Details:
Corrosion Institute of Southern Africa
Bank:
First National Bank
Branch:
Carlswald
Branch code: 250 117
Account No.: 5921 0034 002
Version: 1
Payment method:



Electronic Transfer – proof attached
Cheque enclosed for R ________________
Receipt of payment will be acknowledged
Revision Date: May 2017
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