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FORM A1 / VERSION 02/2011 APPLICATION FOR HOSPERSA MEMBERSHIP A COPY OF THIS APPLICATION MUST BE GIVEN TO HOSPERSA PROVINCIAL OFFICE TO BE COMPUTERISED. I understand that three 3 months for Public Sector or one 1 month s for Private Sector written notice of resignation is required prior to terminating my membership and this stop order. PRIVATE PAYMENTS A fee of R68. 00 pm is applicable with a minimum payment for 6 months. Proof of all payments/ .

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