iCAN Membership Application for Employed Audiologists

Name *

First

Last

Title

Email *

Mobile number *

Date of birth

HPCSA number *

BHF number *

Province *

Practice Name *

Practice Address *

Practice phone number *

Practice email address *

Practice website / URL

Malpractice Insurance by AON is offered at a discounted rate to iCAN members. Should you opt-in for this, you will be invoiced for the annual premium amount. *

Yes - I would like AON cover and will pay the discounted premium
No - I do not require cover

By ticking the box below I acknowledge that my acceptance of the iCAN Code of Conduct and this serves as my legally binding signature acknowledging that I have thoroughly reviewed, understand and accept the iCAN Code of Conduct. The document can be viewed and downloaded here

iCAN Code of Conduct *

I accept

The iCAN Membership Agreement requires you to insert your name, address and signature on the document. Check this box below to confirm that you have read this agreement which can be downloaded HERE. Once completed and signed, you can upload the completed agreement below.

iCAN Membership Agreement *

I accept

Upload your signed Membership Agreement here (.pdf only) *

Click or drag a file to this area to upload.

When clicking "Continue", you will be directed to create your logins for the member-only content and then to PayFast to set up your monthly subscription. If you do not complete ALL these steps, the application can not be processed.