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Debit Order Authorisation Form
I hereby request and authorise the SA Medical Association to draw against my account with the below mentioned bank (or any other bank or branch to which I may transfer my account), the amount necessary for payment of the instalment due for my membership, on the last working day of the next available month end, or mid month, until further notice.

PLEASE NOTE - SAMA NPC is unfortunately no longer in a position to cancel your PERSAL deduction. Should you wish to cancel your PERSAL deduction, you will need to do this directly with your HR department. To assist you, SAMA NPC will forward you a personalised letter, which you will need to submit to your HR department. SAMA NPC will not be held liable for any double deductions in instances where members fail to cancel their PERSAL deductions.

I also wish to indicate that all other terms and conditions as per my current membership with SAMA remains the same.
Email *
SAMA Number (leave blank if you don't know your number)
HPCSA Number *
Name and Surname *
Postal Address *
Contact Tel No *
Account Name *
Debit order *
Deduction Date
Clear selection
Name of Bank *
Branch Name *
Branch Code *
Account Number *
Type of account *
SIGNATURE *
(Type your name and surname)
Date *
MM
/
DD
/
YYYY
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