iCAN Membership Application for Partners Please enable JavaScript in your browser to complete this form.Are you an Independent Audiologist, able to offer patients a choice of manufacturers' products and not bound to any specific brand? *Yes, I am independentNo I am not currently independentIf you answered "No" above, please indicate what avenue of audiology you currently work in *RetailIndustrialRepOtherName *FirstLastTitleEmail *Mobile number *Date of birthHPCSA number *BHF number *Province *GautengKwaZulu NatalWestern CapeNorthern Cape / Free State / Eastern CapeNorth West Province / Limpopo / MpumalangaPractice Name *Who is the iCAN Owner member in your practice?Affiliations *SAAASASLHANABSLHASHAANoneMalpractice 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 premiumNo - I do not require coverBy 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 acceptPLEASE 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 acceptUpload 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. Continue
