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) *

Click or drag a file to this area to upload.

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

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

PLEASE READ FIRST

The iCAN Membership Agreement requires you to insert your name on page 1, your physical and email address on page 9 and your signature in the correct MEMBER space on page 16. Check this box below to confirm that you have read this agreement which can be downloaded HERE. Once completed and signed, you must upload the FULL, completed agreement using the space 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.