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:......