2012 ANNUAL MEMBERSHIP FORM
A. MEMBER Information
Name of Organization or Individual: ......
Contact Person (If Organization):......
Spouse:......
Business Street Address (if organisation):......
Province, City and Code:......
Telephone: (h)...... (w)...... (Cell)......
Fax Number:......
Email Address:......
Specify type of Business/Service/Profession:......
Home Address:......
Province, City and Code:......
B. Church Membership
Home Church:......
Pastor’s Name:......
Pastor’s Tel/Cell No:......
Province, City and Code:......
Local Conference/Field:...... C. Annual Membership Fees 2012: Tick applicable category:
ORGANISATIONAL Non-profit organization R 500.00
Profit Organization: Emerging Businesses (2 employees) R 550.00 Small enterprises (3-9 employees) R 750.00 Medium enterprises (10-25 employees) R1 000.00 Large enterprises (26-39 employees) R1 500.00 Corporate (40+employees) R2 500.00
PROFESSIONAL Entry and middle level professionals R 450.00 Senior Management level R 600.00
Briefly describe your organization’s activities:
D. Statistical Information Total employees including yourself:......
Year operation began:......
E. Commitment Having read the purpose and objectives of ASI and recognizing that my business or profession is a ministry, I desire and pledge to uphold the standards and goals of ASI. I commit my life, office, talents and strengths to sharing Christ in the marketplace.
Signature: ...... Date:......
F. Payment Method (Tick Applicable)
Cash EFT Cheque Debit Order Payments payable to:
BANK - ABSA ACCOUNT NAME - ASI-SAU (Adventist-Laymen’s Services & Industries) ACCOUNT NUMBER - 40-7169-2759 BRANCH CODE - 63-20-05 Business Centre, Bloemfontein
PAYMENT DATE:...... MONTH: ...... 2012
NB: Cash/EFT are payable on receipt of application. If not it must be paid by means of debit order as provided below. Debit Order:
AUTHORITY1 AND MANDATE FOR PAYMENT INSTRUCTIONS Authority given by (NAME OF ACCOUNTHOLDER):......
Address: ......
BANK ACCOUNT DETAILS:
Bank Name:......
Branch name: Town:......
Branch number:......
Account number:......
Account type (CURRENT (CHEQUE)/SAVINGS/TRANSMISSION):......
To (NAME OF BENEFICIARY): ASI-SAU
Beneficiary address: 2 Fairview Street, Bloemfontein, 9300
Membership Application Date: ...... (“the Agreement”)
Signed ...... on this...... day of ......
Payments Period options (Tick applicable)
Monthly Bi-monthly Annually
Payment Date:...... (SPECIFY DATE OF THE MONTH)
This authority and mandate must be given in writing or electronically in terms of the Electronic Communications and Transaction Act, 2002, Chapter 3, Part 1
Please return your completed Annual Registration Form to: ASI SAU Offices Tel: + 27 46 645 2490 Fax:+27 86 244 1674 Email: p [email protected] Skype: asi.sau.ministries
FOR OFFICE USE ONLY Date Received:...... Amount received:...... Registration Number:...... Date Response Sent:......