Name:

Surname:

Where do you live (Place or city):

Cellphone Number: e.g 123-456-7890

Telephone Number: e.g 123-456-7890

Email Address:

Home Address:

HPCSA Registration Number:

Registration Category:

Year of First Registration:

Employment Status: Employed Unemployed

Type (if employed): Permanent Fixed-term Contract Part-time

Current Employer (if employed):

Year of Employment (if employed):

Research Interest: e.g. Cancer, Diabetes, etc

Technical Skills (3-5): e.g. PCR, NGS, GCMS, Microscopy etc

Interpersonal Skills (3-5): e.g. Collaboration, leadership, analytical etc

Interested in becoming a committee member? Yes No Maybe