OTPMG Membership Application/Renewal
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Email *
Title: *
Full Name & Surname *
Profession: *
Required
HPCSA Number (or equivalent): *
Postal Address: *
Physical/Work Address: *
Contact Number: *
Work Contact Number: *
Pain Courses Attended: *
Required
Please specify what other courses you have attended: *
If you are working in South Africa, please specify region by ticking the relevant fields below:  

Region of Physical Work Address: CAPE
Region of Physical Work Address: KWA-ZULU NATAL
Region of Physical Work Address: GAUTENG
Region of Physical Work Address: PRETORIA
Region of Physical Work Address: MPUMALANGA
Region of Physical Work Address: Eastern Cape, please specify location
Region of Physical Work Address: Free State, please specify location
Region of Physical Work Address: Limpopo, please specify location
Region of Physical Work Address: North West, please specify location
Region of Physical Work Address: Northern Cape, please specify location
Region of Physical Work Address: International, please specify location
Membership: *
Required
Student Members must submit the university, year of study as well as the student number in order to qualify for the student membership fee.
Please deposit your membership fees into the following OTPMG bank account and email the proof of payment to info@otpmg.co.za 
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I agree to abide by the rules of Occupational Therapy Pain Management Group Constitution. *
Required
I agree/do not agree to give permission/consent to Occupational Therapy Pain Management Group for the use of my personal/business information listed above to be made available on their website/social media platforms or for use on their "Find an OT" database. *
Required
Date: *
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A copy of your responses will be emailed to the address you provided.
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