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Main > Membership > Join ORSSA

Membership Registration Form

The website is currently experiencing technical issues. To apply to be a member of ORSSA, please complete this <a href="https://docs.google.com/forms/d/e/1FAIpQLSdQveyVh0kh_g7WoOpP4K4qARfMYGYSIr7Y6NhTJJoVW7KiLw/viewform">Google Form</a>


<form action="http://www.orssa.org.za/wiki/formhandler_join_orssa.php" method="post"> <input type="hidden" name="Instructions:" value="ORSSA Database Manager, please process.">

Personal Details

Title*:<select size="1" name="title"><option selected>Select</option><option>Prof</option><option>Dr</option><option>Mr</option><option>Mrs</option><option>Miss</option><option>Ms</option></select>
Initials*:<input type="text" name="initials" size="30"/>
Surname*:<input type="text" name="surname" size="30"/>
Name*:<input type="text" name="name" size="30"/>
Postal Address*:Please type your postal address here.</textarea>
 <input type="text" name="postal_address_1" size="32"/>
 <input type="text" name="postal_address_2" size="32"/>
 <input type="text" name="postal_address_3" size="32"/>
 <input type="text" name="postal_address_4" size="32"/>
Postal Code*:<input type="text" name="post_code" size="4"/>
Country:<input type="text" name="country" size="25">
Telephone Number:<input type="text" name="phone" size="12"/>Please include the area code.
Mobile Telephone Number:<input type="text" name="mobile phone" size="12"/>
Fax Number:<input type="text" name="fax" size="12"/>Please include the area code.
Email Address*:<input type="text" name="email_1" size="30"/>
Alternative Email Address:<input type="text" name="email_2" size="30"/>

Employment Details

Employer*:<input type="text" name="employer" size="40"/>If studying full-time, please use the university as your employer. If retired or unemployed, please indicate it here.
Work Address:Please type your work address / university address / postal address here.
 <input type="text" name="work_address_1" size="32"/>
 <input type="text" name="work_address_2" size="32"/>
 <input type="text" name="work_address_3" size="32"/>
 <input type="text" name="work_address_4" size="32"/>
Postal Code:<input type="text" name="work_post_code" size="4"/>
Work Country:<input type="text" name="work_country" size="25">
Work Telephone Number:<input type="text" name="work_phone" size="12"/>Please include the area code.
Economic Sector*:<select name="economic_sector" size="1" id="economic_sector"><option selected>Select<option>Agriculture &Forestry<option>Mining & Quarrying<option>Manufacturing<option>Electricity, Gas & Water Supply<option>Construction<option>Wholesale & Retail Trade<option>Transport & Logistics<option>Financial, Insurance, Real Estate, Business Services, R&D<option>IT & Communication<option>Public Sector & Defense<option>Education<option>Community, Health, Social & Personal Services<option>Fulltime Student<option>Retired<option>Unemployed<option>Other (Please specify in the text box below)</select>
If other, please specify:<input type="text" name="economic sector: other" size="25"/>
Occupation*:<select size="1" name="occupation"><option selected>Select<option>Managerial (Public Sector)<option>Managerial (Private Sector)<option>Professional<option>Academic/Teaching<option>Technical<option>Fulltime Student<option>Retired<option>Unemployed<option>Other (Please Specify in the text box below)</select>
If other, please specify:<input type="text" name="occupation: other" size="25"/>
Work Experience*:<input type="text" name="work experience" size="2"/> years

Other Information

OR-Related Work Experience*:<input type="text" name="or experience" size="2"/> years
Qualifications*:Please type your qualifications here.
 <textarea name="qualifications" rows="6" cols="55"></textarea>
Degree Majors*:Please type your degree majors here.
 <textarea name="degree majors" rows="6" cols="55"></textarea>
Professional Registrations:Please provide details here of registrations with any other professional societies or institutions besides ORSSA.
 <textarea name="prof_registrations" rows="6" cols="55"></textarea>
Professional Interests:Please briefly describe your professional interests here.
 <textarea name="prof_interests" rows="6" cols="55"></textarea>
Which Chapter Would You Like to Join?*<select size="1" name="chapter"><option selected>Select<option>Johannesburg<option>Kwazulu-Natal<option>Pretoria<option>Vaal Triangle<option>Western Cape</select>
Membership Type*:<select size="1" name="membership_type"><option selected>Select <option>Full Member (RSA & Rest of Africa) (R700 pa) <option>Full Member (Outside Africa) ($90 pa)<option>Full Member (Outside Africa) Rands (R1 230 pa) <option>Student Member (full-time) (R195 pa) <option>Retired Member (R225 pa)<option>Corporate Member</select>
Language Preference:<input type="text" name="language_preference" size="12"/>
Security code*:(:input captcha :)

<input type="submit" value="Submit"/> <input type="reset" value="Clear this Form and Start Over"/>

</form>


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Page last modified on March 12, 2020, at 03:51 PM