iCAN Membership Application for Externs

Confirmation that I am an Independent Audiologist Extern *

I confirm that I am an independent audiologist extern, able to offer patients a choice of manufacturers' products and not bound to any specific brand

Name *

First

Last

Title

Email *

Mobile number *

Date of birth

HPCSA number *

BHF number *

Province *

Employer *

Work address *

Work phone number *

Work email address *

Past / current Community Service institution *

Upload proof of current or post Community Service position (.pdf format) *

Drag & Drop Files, Choose Files to Upload

Estimated date of completion (ie. commserve or studies) *

Affiliations *

By ticking the boxes below, I confirm that these serve as my legally binding signature, acknowledging that I have thoroughly reviewed, understand and accept these points. Documents can be viewed and downloaded below.

Confirm acceptance of the iCAN Rules *

I accept

Click here to read and download the iCAN Rules

Confirm acceptance of the iCAN Code of Conduct *

I accept

Click here to read and download the iCAN Code of Conduct

Confirm acceptance of the iCAN memorandum of Incorporation *

I accept

Click here to read and download the iCAN Memorandum of Incorporation

Confirm acceptance that a verification process will be conducted via the HPCSA prior to my acceptance as a member *

I accept the verification process

Confirm acceptance of the iCAN Membership Agreement, specifically clauses 7.1 and 7.2 *

I accept clause 7.1
I accept clause 7.2

Click here to read and download the iCAN Membership Agreement

PLEASE READ BEFORE CONTINUING

The iCAN Membership Agreement (linked and AGREED to above) requires you to:

insert your name on page 1,
your initials in two places on page 5 (clauses 7.1 & 7.2),
your physical and email address on page 10,
your qualification, HPCSA number and your signature in the correct MEMBER APPLICANT space on page 17

Once completed and signed, you MUST upload the FULL, completed Membership Agreement using the space below.

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

Drag & Drop Files, Choose Files to Upload

When clicking "Continue", you will be directed to create your logins to access the member-only content and then on to PayFast to set up your monthly subscription.

If you do not complete ALL these steps, the application can not be processed.