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LERA SA - Membership Application Form
This application form is only for NEW Members Joining LERA SA, and should be completed ONLINE. Complete the form and press Submit at the end.
DO NOT PRINT this form from the website, you will receive a copy by email for your records
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Email
*
Your email
PERSONAL DETAILS
Title (Mr/Mrs/Doc/Prof)
Your answer
Surname
*
Your answer
Full Names
*
Your answer
Preferred Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
SA ID Number
*
Your answer
Full Residential Address
*
Your answer
Cell Phone Number
*
Your answer
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