| Organisation Details |
|---|
| Name: |
|
| Postal Address: |
|
| Phone: |
|
| Email: |
|
| Details of Contact Person |
|---|
| Name: |
|
| Position: |
|
| Phone: |
|
| Cell: |
|
| Fax: |
|
| Email: |
|
| Type of registration and reference number |
|---|
Type of registration,
(NPO, Section 21 Company, Trust, etc.): |
|
| Registration No.: |
|
| Main aims of organisation |
|---|
|
| Affiliation |
|---|
| Is the organisation affiliated to a larger organisation?:
Yes
No
|
| If Yes provide name: |
|
| Geographic extent of services (including affiliates, branches, etc.) |
|---|
| Do your services extend to: - |
| More than 1 province?
Yes
No
|
| If yes, name the provinces: |
|
| NB: Please provide a list of your branches/ affiliates and their contact details |
| Throughout one province?
Yes
No
|
| If yes name the province: |
|
| A region within 1 province?
Yes
No
|
| If yes, describe the area: |
|
| A specific local area?
Yes
No
|
| If yes, name the city area or magisterial district: |
|
| Is the organisation committed to transformation in terms of its governance, personnel and beneficiaries of services?
|
| Does the organisation have a transformation plan?
|
| What are your expectations from becoming a member of NACOSS?
|
| Where / from whom did you hear about NACOSS?
|
| Any other information or comments
|
| Your Name:
|
|
| Date:
|
