<p>2012 ANNUAL MEMBERSHIP FORM</p><p>A. MEMBER Information </p><p>Name of Organization or Individual: ...... </p><p>Contact Person (If Organization):...... </p><p>Spouse:...... </p><p>Business Street Address (if organisation):...... </p><p>Province, City and Code:...... </p><p>Telephone: (h)...... (w)...... (Cell)...... </p><p>Fax Number:...... </p><p>Email Address:...... </p><p>Specify type of Business/Service/Profession:...... </p><p>Home Address:...... </p><p>Province, City and Code:...... </p><p>B. Church Membership </p><p>Home Church:...... </p><p>Pastor’s Name:...... </p><p>Pastor’s Tel/Cell No:...... </p><p>Province, City and Code:...... </p><p>Local Conference/Field:...... C. Annual Membership Fees 2012: Tick applicable category: </p><p>ORGANISATIONAL Non-profit organization R 500.00</p><p>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</p><p>PROFESSIONAL Entry and middle level professionals R 450.00 Senior Management level R 600.00</p><p>Briefly describe your organization’s activities: </p><p>D. Statistical Information Total employees including yourself:...... </p><p>Year operation began:...... </p><p>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. </p><p>Signature: ...... Date:...... </p><p>F. Payment Method (Tick Applicable)</p><p>Cash EFT Cheque Debit Order Payments payable to:</p><p>BANK - ABSA ACCOUNT NAME - ASI-SAU (Adventist-Laymen’s Services & Industries) ACCOUNT NUMBER - 40-7169-2759 BRANCH CODE - 63-20-05 Business Centre, Bloemfontein</p><p>PAYMENT DATE:...... MONTH: ...... 2012</p><p>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: </p><p>AUTHORITY1 AND MANDATE FOR PAYMENT INSTRUCTIONS Authority given by (NAME OF ACCOUNTHOLDER):...... </p><p>Address: ...... </p><p>BANK ACCOUNT DETAILS:</p><p>Bank Name:...... </p><p>Branch name: Town:...... </p><p>Branch number:...... </p><p>Account number:...... </p><p>Account type (CURRENT (CHEQUE)/SAVINGS/TRANSMISSION):...... </p><p>To (NAME OF BENEFICIARY): ASI-SAU</p><p>Beneficiary address: 2 Fairview Street, Bloemfontein, 9300</p><p>Membership Application Date: ...... (“the Agreement”)</p><p>Signed ...... on this...... day of ...... </p><p>Payments Period options (Tick applicable)</p><p>Monthly Bi-monthly Annually</p><p>Payment Date:...... (SPECIFY DATE OF THE MONTH)</p><p>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</p><p>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</p><p>FOR OFFICE USE ONLY Date Received:...... Amount received:...... Registration Number:...... Date Response Sent:...... </p>
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