Microfinance South Africa

Tel: 012 346-1081 Fax: 012 346 1082 E-mail: [email protected] APPLICATION FOR MEMBERSHIP PLEASE PRINT, COMPLETE AND FAX TO (086 694 5444)

I:………………………………………………………………………………………………………………..hereby apply on behalf of……………………..………………………………………………………………….(CC) for membership of MicroFinance South Africa (MFSA) as from the month of ______20___ and undertake to pay the inclusive monthly subscription of R 872.10 or the annual amount of R 10,465.20 (or as may be adjusted from time-to-time) and to abide by the Articles of Association at all times. I understand that in terms of the Statutes, all membership rights lapse after three (3) months of non-payment of subscriptions, and in the case of me wishing to terminate my membership I will notify the MFSA with 3-month’s notice.

BUSINESS NAME:______

Postal Adress______

Town______Postal Code:______Region:______

Business Address______

______

Tel: (_____)______Fax:(______) ______

E-mail address:______

NCR / No:______Business Registration: ______

VAT NO:______

CONTACT PERSON: Mr/Mrs/Me:______ID:______Cell No:______

Registration number: 1996/001116/08 Surname:______Names:______

Signature:______Date:______

ASSOCIATE MEMBER ONCE OFF PAYMENT R 10 465.20 or monthly R 872.10

Enquiries Members: Uncial [email protected] Accounts: Dorien [email protected]

THE ABOVE AMOUNTS ARE INCLUSIVE OF VAT Type of payment:  Cheque  Cash  Bank deposit  Debit order (Fax deposit slip to) 012 346 1082