APPLICATION FOR CERTIFICATION / REGISTRATION

Please complete ALL fields

Area of interest :
Your ultimate goal with registration :
Surname :
Name :
Date of Birth :
Place of Birth :
Residential Address :
Postal Address :
Tel No :
Fax No :
E-mail :
Languages spoken :
Employer Name :
Employer Address :
HIGHER EDUCATION
List Certificates, diplomas, degrees etc. obtained (State Qualification, Institution, Date obtained):
Supplementary courses, professional examinations, professional registrations, licenses and membership of professional bodies, etc.:
Citations, awards, publications, professional commitments etc.:
Employment history (mention job description and related supporting information):
Motivation for your application for registration:
Names of referees/persons recommending/supporting your application (two or three persons who can verify and support any statement(s) made):
Payment Method (* South African Applicants only)       |      view DTMSI bank account details Elec. Transfer   Draft    Cheque    Postal Order   Online (using PayPal) Direct payment into DTMSI bank account* Credit Card
For Credit Card Payment Only (complete ALL fields): PLEASE NOTE: credit card details will be                encrypted before transmitted over the Internet!		We accept

Credit card in the name of :
Credit Card Number :
Credit Card Type :	--Please Select-- VISA MASTERCARD OTHER
If Credit Card type is set to "OTHER" please enter :
Expiry Date :	--Please Select-- 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 (Year) --Please Select-- 01 02 03 04 05 06 07 08 09 10 11 12 (Month)
CVV Number (Last 3 digits on back of card) :
Amount :

DTMSI Bank Account Details (Kindly fax a copy of your deposit slip for our convenience):
Bank	First National Bank
Account Name	Design, Technology and Management Society International
Account Type	Current
Branch Code	20013
Account Number	62066368294
OVERSEAS	SWIFT FRINZAJJ Refer to the bank and the DTMSI account details as above

PLEASE ENSURE THAT YOU UNDERSTAND THE FOLLOWING: DECLARATION BY THE CANDIDATE By submitting this application I certify that the above information is correct. I have read and understand the registration requirements and procedures and relative Society information., Enclosed with this application are CERTIFIED COPIES of my documents, i.e. Certificates, Diplomas, Degrees, Transcripts, Resume and Supporting Information. BEFORE SUBMITTING, PLEASE PRINT A COPY OF THIS FORM FOR YOUR RECORDS