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DAF Membership form 2022
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* Indicates required question
Do you
apply for membership of Dialogues for An Anti-Capitalist Future?
*
Yes
No
PERSONAL DETAILS
First Name
*
Your answer
Surname
*
Your answer
ID Number
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Province
*
Your answer
Postal code
*
Your answer
EMPLOYMENT / UNEMPLOYMENT
Are you employed?
*
Employed
Unemployed
ORGANISATION (if Applicable)
Your answer
Position in Organisation (if Applicable)
Your answer
TRADE UNION (if Applicable)
Your answer
Position in Trade Union (if Applicable)
Your answer
BANK DETAILS (debit order)
Name of Bank
Your answer
Account in the name of
Your answer
Account Number
Your answer
Branch Name
Your answer
Branch Code
Your answer
Payment Period (e.g monthly)
*
Choose
Monthly
Annual
Transaction Start Date:
*
MM
/
DD
/
YYYY
Deduction day of month
*
Choose
1
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Transaction Reference
*
Your answer
Please select your income/monthly payment
*
Choose
R0 - R1,000 (R10/month)
R1,000 - R2,000 (R30/month)
R2,000 - R3,000 (R50/month)
R3,000 – R5,000 (R70/month)
R5,000 – R7,500 (R100/month)
R7,500 – R10,000 (R150/month)
R10,000 – R15,000 (R250/month)
R15,000 – R20,000 (300/month)
R20,000 + (R500/month)
AUTHORISATION
Do you grant permission to the Dialogues for An Anti-Capitalist Future to retrieve funds due as outlined above?
*
Yes
No
Do you grant permission to the Dialogues for An Anti-Capitalist Future to use your personal information to build an anti capitalist future?
*
Yes
No
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