OPEN FOR REGISTRATION
Annual Fees:
R 400 for main member
or
R 600 for family
BANK DETAIL
Bank: FNB
Account Name: STEINITZ
Account no: 62804544064
Branch: CAPE GATE
Branch Code : 250655
Account Type: Current Account
Please email proof of payment and direct any payment queries to Ilze de Kock -
Ilze@accprof.co.za
Please answer all the questions
* Required
First Name(s)
*
Main Member First Name
Your answer
Surname
*
Main Member Surname
Your answer
Gender
*
Main Member Gender
Male
Female
Residential Address
*
Your answer
E-Mail Address
*
Your answer
Cell Phone Number
*
Do not type hyphens or spaces.
Your answer
Landline
Do not type hyphens or spaces.
Your answer
Main Member Date of Birth
*
MM
/
DD
/
YYYY
Direct Family Member1 First Name(s)
Your answer
Direct Family Member1 Surname
Your answer
Direct Family Member1 Date of Birth
MM
/
DD
/
YYYY
Direct Family Member2 First Name(s)
Your answer
Direct Family Member2 Surname
Your answer
Direct Family Member2 Date of Birth
MM
/
DD
/
YYYY
Direct Family Member3 First Name(s)
Your answer
Direct Family Member3 Surname
Your answer
Direct Family Member3 Date of Birth
MM
/
DD
/
YYYY
Direct Family Member4 First Name(s)
Your answer
Direct Family Member4 Surname
Your answer
Direct Family Member4 Date of Birth
MM
/
DD
/
YYYY
Undertaking
*
I undertake to adhere to the principles, rules and regulations of Steinitz CHESS CLUB
Yes
No
Payment
*
I still have to make payment
I have already made payment
Other:
Payment Amount Paid or To Be Paid
*
Please do NOT type R for Rands • Simply type the number
Your answer
Payment Description
Please take a moment to describe what payment was made for (in words), which will help us identify deposits.
Your answer
Comments
Please indicate anything further which you feel we should know about, including disabilities.
Your answer
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