I would like to become a member. Comple ng this form means that I agree to abide by the rules, code of conduct and the cons tu on of the Healthcare Organisa on. PERSONAL DETAILS Title Dr / Mr / Ms / Mrs Member No Name Surname ID No : Residen al/Postal Address Cell Tel (H) Tel (W) Email EMPLOYMENT DETAILS Department Ins tu on Unit Employee No Province Region Sector Private / Public / NGO Work Tel No BANKING DETAILS Account Holder Bank Name Branch Name Branch Code Account No Account Type DECLARATION I hereby declare that the informa on provided on this form is true and correct and that should any of my details change, it is my responsibility to inform HAITU of the changes. I further understand that HAITU reserves the right to terminate a recruiter’s services in the event of misconduct and fraud. The Recruiter absolves HAITU from any liability in terms of POPIA for failing to obtain the recruiter’s consent or to no fy the recruiter of the reason for the processing of any of his/her personal informa on. Signature: __________________ Date: _____________________ FOR OFFICE USE ONLY Applica on Status Approved / Declined Reason for Decline Applica on Approved By: Name Surname Signature Date Recruiter No. H A I T U R E C R U I T E R ’ S A P P L I C A T I O N F O R M 7th Floor Howard House 23 Loveday Street Marshalltown Johannesburg 2001 H E A D O F F I C E Health & Allied Workers Indaba Trade Union (HAITU) HAITU O n e S e c t o r = O n e U n i o n H e a l t h S e c t o r = H A I T U Health & Allied Workers INDABA TRADE UNION 11 Walnut Road Kingsmead Durban 4001 031 003 2967 Ofce 35 Bindulavhathu Complex Thohoyandou Limpopo K Z N O F F I C E L I M P O P O O F F I C E Health & Allied Workers Indaba Trade Union (HAITU) Health & Allied Workers Indaba Trade Union (HAITU) Health & Allied Workers Indaba Trade Union (HAITU) HAITUTV Health & Allied Workers Indaba Trade Union (HAITU)