Celebrating 25 years of uniting nurses

Elementor #4252

    Title*

    Initials*

    Surname*

    First Names*

    Maiden Name

    Postal Address*

    ID No.

    Passport No.

    Date of Birth*

    Gender*

    SANC No.

    Race*

    Salary/ Persal No

    Employer Name and Address*

    Date of joining DENOSA*

    Province*

    Region*

    Cell No.*

    Tel No

    Email

    Position*

    Speciality

    I give DENOSA permission to share my information in confidence for my benefit.

    Recruited By*

    Payment Method*

    Bank Name*

    Branch Name*

    Branch Code*

    Account Number*

    Type of Account*

    Debit date*

    THAT THE PARTY HEREBY AUTHORISED TO EFFECT THE DRAWINGS AGAINST MY ACCOUNT MAY NOT CEDE OR ASSIGN ANY OF ITS RIGHTS TO ANY THIRD PARTY WITHOUT MY PRIOR WRITTEN CONSENT.

    First Debit Order Date*


    I hereby authorise you to deduct the monthly subscription of R36 for students per month and R86 for all nurses per month.

    Business Trading Name: DENOSA

    Name of bank: FNB

    Bank Account No: 514 251 652 84

    Type of Account: Cheque

    Branch Code: 251 445

    City/ town of Bank: Pretoria

    Fax No: (012) 343-3622

    Reference No: Membership No. or 1st nine digits of your ID No.