composer / author application for samro membership a. personal ...

AFFILIATED TO THE INTERNATIONALCONFEDERATION OF COPYRIGHTSOCIETIES–CISAC(Reg. No. 1961/002506/07)P O Box 31609Braamfontein 2017TEL: (011) 712 8000FAX: +27(0)86 674 4391Email: 24-7@samro.org.zaCOMPOSER / AUTHOR APPLICATION FOR SAMRO MEMBERSHIPINSTRUCTIONS1. PLEASE USE BLOCK LETTERS AND A BLACK PEN TO COMPLETE.2. PLEASE ATTACH A COPY OF YOUR ID / PASSPORT TO THE COMPLETEDAPPLICATION.A. PERSONAL DETAILSTitleMr Ms Mrs Dr Prof RevSurnameFull Name(s)ID / Passport NumberDate of Birth (YYYY-MM-DD)

Residential AddressPostal AddressCountry of BirthNationalityGenderMaleFemaleContact DetailsTel (H/W)Cell / MobileE-mail Address

B. BANKING DETAILSBank NameAccount HolderAccount NumberAccount TypeCheque Savings / Mzansi Transmission OtherBranchBranch CodeC. RIGHTS TO BE ADMINISTERED BY SAMROPerforming RightsMechanical Rights

DECLARATIONI hereby apply to be admitted as a member of SAMRO in terms of its Memorandumand Articles of Association. If admitted, I agree to abide by the terms of thosedocuments as well as SAMRO’s Rules and Regulations.I hereby declare that I am not a member of any Performing and / or MechanicalRights organisation or society in any other country, or SAMRO territory and that thedetails contained in this Application Form are correct.Signed atOn this day of 20Applicant’s Signature(The form must be signed by your parent / guardian if you are under 18 years of age).Return completed form to:SAMRO Writer Services DepartmentP.O. Box 31609Braamfontein2017