REGISTRATION FORM

2008

REGISTRASIEVORM

1

CHESS SOUTH AFRICA

SKAAK SUID-AFRIKA

Registration Officer

CHESSA Bank Details

Günther van den Bergh

Bank:  First National Bank

 

Branch: CRESTA / 254905

Cell: 079 797 8071  Email: Gunther@chesscube.com

Account number:  58810045419

Personal / Persoonlik

Surname:
Van:

 

Full names:
Volle voorname:

 

Title (circle):
Tietel (omkring):

Dr.   Prof.   Adv.   Mr.   Mnr.   Mrs.   Miss.   Mev.  

Gender (circle):
Geslag (omkring):

Male/Manlik     Female/Vroulik

Race (Circle):
Ras (Omkring):

White/Wit     Black/Swart   Coloured/Kleurling Indian/Indiër    Asian/Asiër    Other/Ander(specify):__________________________

Are you disabled:
Is u gestrem:

Yes/Ja     No/Nee

Date of birth:
Geboortedatum:

Year
Jaar

 1 2 2 2

Month
Maand

    

Day
Dag

    

ID number:
ID nommer:

Above personal information required by SASC & SRSA for development funding purposes.
Bogenoemde persoonlike inligting benodig deur SASC & SRSA vir ontwikkelings befondings doeleindes.

Postal address / Posadres

______________________________

______________________________

______________________________

______________________________

Code / Kode:  ____________________________

Contact details / Kontak besonderhede

Tel (H):

  

Tel (B):

  

Fax/Faks:

  

Cell/Sel:

  

E-mail/E-pos:

  

Province/Region/Union in RSA          Provinsie/Streek/Unie in RSA

Mark with a “X”     Merk met ‘n “X”


[   ] Border (EB)                       [   ] Eastern Province (EP)                 [   ] Northern Free State (FN)             [   ] Free State (FS)

[   ] Ekurhuleni (EK)                      [   ] Mid-Gauteng (GM)                        [   ] Gauteng North (GN)                     [   ] Sedibeng (SED)

[   ] Gauteng South (GS)              [ ] Gauteng West (GW)                    [   ] KwaZulu Natal North (KNN)       [   ] KwaZulu Natal (KZN)

[   ] Limpopo (LIM)                        [   ] Mpumalanga Highveld (MH)            [   ] Mpumalanga Lowveld (ML)       [   ]Northern Cape (NC)

[   ] Northwest Province (NWP)   [   ] Platina (PLA)                                 [   ] South Western Districts (SWD) [   ] Boland (WB)
[   ] Western Province (WP)

I undertake to adhere to the principles, rules and regulations of Chess South Africa (CHESSA)
Ek onderneem om my te verbind aan die beginsels, reels en regulasies van Skaak Suid-Africa (SKAAKSA)

Amount paid:                                 Signature:                                                          Date:
Bedrag betaal: ___________    Handtekening: _______________________    Datum: _________________

Fees / Fooie:        Senior (21 years and older): R120               Junior (20 years and younger): R60

2

Receipt / Kwitansie

Received from/Ontvang van: __________________________________    

Place/Plek: __________________________________

Amount paid/Bedrag betaal: __________     Date/Datum: _____________
                                                                                                                                                                          
Receiver of money and form/Ontvanger van geld en form: _________________________   

Signature / Handtekening: ________________